Report AP-16-022 - City of Kingston

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Report AP-16-022 - City of Kingston
City of Kingston
Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
To:
Chair, Rideaucrest Home Board of Management
From:
Lanie Hurdle, Commissioner, Community Services
Resource Staff:
Debra Skeaff, Administrator, Rideaucrest Home
Date of Meeting:
September 8, 2016
Subject:
Rideaucrest Home Report for June - August 2016
Executive Summary:
This report is the fourth of the bi-monthly reporting that is provided to the Rideaucrest Board of
Management for 2016. The report includes statistical information on key indicators that are
being reported to the Ministry of Health and Long Term Care as well as information on
operations of the Home.
This report contains information from June 11, 2016 through August 18, 2016.
Recommendation:
This report is for information purposes only.
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Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
September 8, 2016
Page 2 of 6
Authorizing Signatures:
ORIGINAL SIGNED BY COMMISSIONER
Lanie Hurdle, Commissioner, Community Services
ORIGINAL SIGNED BY CHIEF ADMINISTRATIVE OFFICER
Gerard Hunt, Chief Administrative Officer
Consultation with the following Members of the Corporate Management Team:
Denis Leger, Commissioner, Corporate & Emergency Services
Not required
Jim Keech, President and CEO, Utilities Kingston
Not required
Desiree Kennedy, Chief Financial Officer & City Treasurer
Not required
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Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
September 8, 2016
Page 3 of 6
Options/Discussion:
Operational Information and Data
Rideaucrest Home has maintained an occupancy rate of 99.35% in June, 99.62% in July and
100% thus far in August. The year to date occupancy rate is 99.3%. Maintaining a high
occupancy rate is important to leverage provincial funding which is based on daily envelopes
per resident and the Case Mix Index (CMI).
With the goal of maintaining over 98% occupancy in mind, Rideaucrest Home went live with
Community Care Access Centre’s (CCAC) data integration portal on June 15, 2016. All
referrals, updates and admission information for potential residents is loaded from the CCAC
case workers into the web based portal for traceable, auditable and consistent information flow
between the organizations. The availability of this information is key for timely admissions when
bed vacancies arise.
Rideaucrest Home had 10 incidents reportable to the Ministry of Health and Long Term Care
(MOHLTC) during this reporting period.
There are currently 389 people on the waiting list for the Home. 213 of those waiting are 4A
priority who are actively seeking/requiring admission to Long Term Care.
Two inspectors from the MOHLTC visited the Home June 27, 2016 through July 6, 2016 to
follow up on 16 Critical Incidents and 1 Complaint. During this comprehensive inspection
process, the Home received 2 Written Notifications related to one critical incident, and 1 Written
Notification and an associated Voluntary Plan of Correction for a second critical incident.
Extendicare statistics for average results of Assist Homes are 11 Written Notifications, 5
Voluntary Plans of Correction and 1 Order. The Local Health Integration Network (LHIN)
statistics for average results are 6 Written Notifications, 2 Voluntary Plans of Correction and 1
Order. Both inspectors gave the Home great praise for the work and plans in place, they were
very satisfied overall with the operations at Rideaucrest Home. Both inspectors’ Public Reports
are attached as Exhibits A to E.
The Home is continually preparing for Accreditation Canada to visit September 12–14, 2016.
There are 4 Standards that the Accreditation Canada Surveyors review and evaluate while
inspecting practices in the Home: Leadership, Long Term Care, Medication Management and
Infection Control. In addition to the standards, the Surveyors will review 31 Required
Organization Practices (ROPs) which are covered in 6 categories: Safety Culture,
Communication, Medication Use, Worklife/Workforce Balance, Infection Control and Risk
Management. There are interdisciplinary teams in place reviewing the standards and updating
policies and procedures in preparation for September.
Renovations are underway by Cupido Construction in preparation for the Allen-Detweiler
Nursery School (ADNS) joining Rideaucrest. The Life Enrichment Coordinators, their newly
hired Supervisor, Ashley Miller, and ADNS staff are working on plans for intergenerational
programming to commence in October/November 2016.
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Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
September 8, 2016
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Rideaucrest is thrilled to have the terrace upgrades (wallpaper removal, patching, application of
wall protector to lower half of walls and painting) in progress. The project plans are in place and
a work schedule started on August 29th. Surveys are out so that residents have input on
choosing colours, and a detailed plan is in place for notifying residents and families of work that
will take place in their home and timelines to be expected.
With guidance from the Best Practice Champion Lead and Assistant Directors of Care, the
Home made a Capital purchase of 27 bolstered raised edge mattresses and 9 convertible air
surface high intensity mattresses with pumps. The bolstered mattresses were mainly given to
residents who had patterns of falls from bed and since their application in early July 2016 there
has not been a fall from bed. Staff will continue to monitor this conclusion and if improved trends
continue to be reported by the Falls Committee, staff will be considering this model for future
purchases.
Financials
The approved 2016 operational budget for Rideaucrest Home is $5,225,323 in municipal
contribution. As of the end of June 2016, Rideaucrest Home has spent 52% of its municipal
contribution, which is 2% or $104K over budget. Provincial subsidy revenues are $61K greater
than budget as the 2016 budget was built with an assumed CMI of 95.28 and effective April 1st,
the CMI increased to 98.95.
Areas over budget include nursing wages (YTD $161K) which include $67K in two unbudgeted
positions of accommodated workers and incremental budget for modified workers YTD. High
intensity needs claim based funding is $26K lower than budget, however, this aligns with the
overtime budget being in surplus year to date.
Environmental services wages are $31K overspent due to an increase in modified work
routines. Lease of City Property is under budget by $14K as the Nursery School will not begin
their lease until September 2016.
Dietary food supplies are $21K overspent, the Food Service Supervisor is working closely with
Extendicare consultants to make menu modifications and budget tracking to ensure this trend
does not follow through year end. Dietary wages are $37K overspent due to three modified
workers in the department.
Overall accommodation revenue is higher than budget by $9K at the end of June. The MOHLTC
announced Level of Care funding increases on June 30, 2016, retroactive to April 1, 2016
(Exhibit F). In terms of year over year actual funding impact, the combined CMI increase
previously reported and the current 2% funding rate increase provides an additional $330K
($120K 2% rate, and $210K CMI) of revenues for the period April 1, 2016 - March 30, 2017. The
Home has been in contact with the LHIN regarding the Raw Food and Other Accommodation
envelope funding increases. Funding increases for these are not yet released, but is estimated
to be a 1% increase; and a total of $38K higher revenues is built into the 2016 budget.
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Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
September 8, 2016
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Ministry of Health and Long Term Care Indicators
Rideaucrest’s quality improvement plan is based on predetermined indicators. The quarterly
Canadian Institute for Health Information (CIHI) Home specific results versus the Province for
Q4 2015/16 (January – March 2016) are attached as Exhibit G to this report. Ideally, long term
care homes should be performing at the same level or better than the provincial average.
Rideaucrest is higher in some areas.
The Home implemented a full time Best Practice Champion Lead in 2016 and this position has
been focusing on bed side education in areas identified for quality improvement. Rideaucrest
went live with the electronic point of care (POC) documentation in 2016. This system has great
benefits for accuracy, trending and reporting, but its implementation has also been an
adjustment for staff which could be part of the fluctuations seen across the reporting indicators
as education continues with this new system.
Stage 2-4 pressure ulcers have risen over the last reporting quarter. This is attributed to
accuracy in staging. The Assistant Director of Care (previously the wound care nurse) has been
educating the Best Practice Champion Lead on the accuracy of staging (i.e. sheering is not
considered a pressure ulcer).
Falls have increased, yet the daily physical restraints remain below the LHIN. The home
invested in 27 raised bolstered edge mattresses, which to date are making a great difference in
falls from bed. The physiotherapy team has marked the walls in each resident room to indicate
the appropriate bed height relative to fall risk. There were two outbreaks in this CIHI reporting
period and higher falls is often correlated with people being unwell.
Use of antipsychotics without diagnosis of psychosis in trending downward which is attributed to
a MOH funded program that the Administrator, Director of Care, Medical Director and Nurse
Practitioner have attended regarding inappropriate prescribing of antipsychotic medications.
Finally, worsened bladder incidents have risen and the RAI Coordinator is following trends that
are documented in the POC system, monitoring declines and auditing for accuracy. The home
began a trial on a new continence product system May 30, 2016. The trial has been successful
and it is expected to impact results in upcoming CIHI statistics.
Options/Discussion:
Not applicable
Existing Policy/By-Law:
Not applicable
Notice Provisions:
Not applicable
108
Information Report to Rideaucrest Home Board of Management
Report Number AP-16-022
September 8, 2016
Page 6 of 6
Accessibility Considerations:
Not applicable
Financial Considerations:
Not applicable
Contacts:
Lanie Hurdle, Commissioner, Community Services 613-546-4291 extension 1231
Deb Skeaff, Administrator, Rideaucrest Home 613-530-2818 extension 4252
Other City of Kingston Staff Consulted:
Laura Christopher, Supervisor, Finance & Administration, Rideaucrest Home
Exhibits Attached:
Exhibit A
2016_236622_0020 Inspection Report Public
Exhibit B
2016_236622_0021 Inspection Report Public Copy
Exhibit C
2016_444602_0022 Inspection Report Public Copy
Exhibit D
2016_444602_0023 Inspection Report Public Copy
Exhibit E
2016_444602_0024 Inspection Report Public Copy
Exhibit F
Level-of-Care Base Increase Funding 2016-17
Exhibit G
Q4 CIHI Jan to March 2016 Indicators
109
Exhibit A
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
Ottawa Service Area Office
347 Preston St Suite 420
OTTAWA ON K1S 3J4
Telephone: (613) 569-5602
Facsimile: (613) 569-9670
Bureau régional de services d’Ottawa
347 rue Preston bureau 420
OTTAWA ON K1S 3J4
Téléphone: (613) 569-5602
Télécopieur: (613) 569-9670
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Jul 7, 2016
Log # /
Type of Inspection /
Registre no
Genre d’inspection
2016_236622_0020 014513-16 /008113-14 / Critical Incident
000471-14
System
Licensee/Titulaire de permis
THE CORPORATION OF THE CITY OF KINGSTON
216 Ontario Street KINGSTON ON K7L 2Z3
Long-Term Care Home/Foyer de soins de longue durée
RIDEAUCREST HOME
175 RIDEAU STREET KINGSTON ON K7K 3H6
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
HEATH HEFFERNAN (622)
Inspection Summary/Résumé de l’inspection
The purpose of this inspection was to conduct a Critical Incident System
inspection.
This inspection was conducted on the following date(s): June 27, 28, 29, 30 2016
and July 04, 05, 06, 2016.
During the course of the inspection, the inspector(s) spoke with the Administrator,
the Assistant Directors of Care, a Registered Nurse, a Personal Support Worker
and the residents.
The following Inspection Protocols were used during this inspection:
Page 1 of/de 3
110
Exhibit A
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Falls Prevention
During the course of this inspection, Non-Compliances were not issued.
0 WN(s)
0 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
Legend
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
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111
Issued on this
7th
Exhibit A
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
day of July, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 3 of/de 3
112
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
Ottawa Service Area Office
347 Preston St Suite 420
OTTAWA ON K1S 3J4
Telephone: (613) 569-5602
Facsimile: (613) 569-9670
Bureau régional de services d’Ottawa
347 rue Preston bureau 420
OTTAWA ON K1S 3J4
Téléphone: (613) 569-5602
Télécopieur: (613) 569-9670
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Jul 7, 2016
Log # /
Registre no
2016_236622_0021 011822-16 / 008202-16
/ 004650-16
Type of Inspection /
Genre d’inspection
Critical Incident
System
Licensee/Titulaire de permis
THE CORPORATION OF THE CITY OF KINGSTON
216 Ontario Street KINGSTON ON K7L 2Z3
Long-Term Care Home/Foyer de soins de longue durée
RIDEAUCREST HOME
175 RIDEAU STREET KINGSTON ON K7K 3H6
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
HEATH HEFFERNAN (622)
Inspection Summary/Résumé de l’inspection
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113
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
The purpose of this inspection was to conduct a Critical Incident System
inspection.
This inspection was conducted on the following date(s): June 27, 28, 29, 30 2016
and July 04, 05, 06, 2016.
During this inspection the following critical incident inspections were completed;
M569-000018-16 - alleged staff to resident abuse/neglect
M569-000013-16 - alleged staff to resident abuse/neglect
M569-000006-16 - alleged staff to resident abuse/neglect
During the course of the inspection, the inspector(s) spoke with the Administrator,
the Assistant Director of Care, Registered Nurses, Registered Practical Nurses,
Personal Support Workers and the residents.
The following Inspection Protocols were used during this inspection:
Dignity, Choice and Privacy
Medication
Personal Support Services
Prevention of Abuse, Neglect and Retaliation
During the course of this inspection, Non-Compliances were issued.
2 WN(s)
0 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
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114
Legend
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
WN #1: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 6.
Plan of care
Specifically failed to comply with the following:
s. 6. (5) The licensee shall ensure that the resident, the resident’s substitute
decision-maker, if any, and any other persons designated by the resident or
substitute decision-maker are given an opportunity to participate fully in the
development and implementation of the resident’s plan of care. 2007, c. 8, s. 6 (5).
Findings/Faits saillants :
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115
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
1. The licensee has failed to ensure that the resident, the SDM, if any, and the designate
of the resident / SDM been provided the opportunity to participate fully in the
development and implementation of the plan of care.
The following finding is related to log 004650-16
On a specified date resident #002 reported to the Registered Nurse #105 that the
registered practical nurse (RPN) #101 had administered him/her a medication without
obtaining consent.
In an interview on July 4, 2016, RPN #101 explained that on a specified date he/she
informed resident #002 he/she required a medication. RPN #101 reported that resident
#002 did not see his/her face and may have had difficulty hearing him/her. RPN #101
then indicated it would have been best to have ensured he/she obtained consent,
however he/she did not. RPN #101 confirmed he/she administered the medication to
resident #002.
July 4, 2016 inspector #622 reviewed the medical directive procedure - Rideaucrest
Home specific policy PHA-13-500.00 dated October 18, 2015 which indicated direction
pertaining to the administration of the specified medication.
On July 04, 2016, at 1130 hours, inspector #622 interviewed the Assistant Director of
Care #103 who confirmed that it was his/her understanding from his/her investigation into
the incident that RPN #101 had not made the care direction clear to the resident.
On July 05, 2016 inspector #622 interviewed resident #002 who indicated that RPN #101
had not informed him/her, he/she was going to give the medication before administering
it on the specified date. Resident #002 confirmed he/she was given the medication
without knowledge and was not given a choice as to the treatment or care provided.
As resident #002 was not provided clear direction regarding nor had he/she consented to
the care provided, he/she was not afforded the opportunity to participate in the
implementation of her plan of care. [s. 6. (5)]
WN #2: The Licensee has failed to comply with O.Reg 79/10, s. 30. General
requirements
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116
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Specifically failed to comply with the following:
s. 30. (2) The licensee shall ensure that any actions taken with respect to a
resident under a program, including assessments, reassessments, interventions
and the resident’s responses to interventions are documented. O. Reg. 79/10, s.
30 (2).
Findings/Faits saillants :
1. The licensee has failed to ensure that any actions taken with respect to a resident
under a program, including assessments, reassessments, interventions and the
resident's responses to interventions are documented.
The following finding is related to log 004650-16
Long Term Care Homes Act section 8(1) every licensee of a long-term care home shall
ensure that there is, (a) an organized program of nursing services for the home to meet
the assessed needs of the residents.
On a specified date, resident #002 reported to the Registered Nurse (RN) #105 that
Registered Practical Nurse (RPN) #101 had administered him/her a medication without
obtaining consent.
During the inspection, resident #002’s personal health information including; the
electronic medication administration record (eMAR), the electronic treatment
administration record (eTAR) and progress notes on point click care were reviewed and
revealed no documentation had been completed to indicate the medication had been
administered, nor the effect of the medication administered that specified date.
On July 04, 2016 inspector #622 interviewed the Assistant Director of Care who indicated
the administration of the medication to resident #002 was not documented.
On July 04, 2016 inspector #622 interviewed Registered Practical Nurse (RPN) # 101
who confirmed he/she had not documented regarding the medication he/she gave to
resident #002 or the results of the medication administered during his/her shift on the
specified date. [s. 30. (2)]
Page 5 of/de 6
117
Issued on this
7th
Exhibit B
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
day of July, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 6 of/de 6
118
Exhibit C
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
Ottawa Service Area Office
347 Preston St Suite 420
OTTAWA ON K1S 3J4
Telephone: (613) 569-5602
Facsimile: (613) 569-9670
Bureau régional de services d’Ottawa
347 rue Preston bureau 420
OTTAWA ON K1S 3J4
Téléphone: (613) 569-5602
Télécopieur: (613) 569-9670
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Jul 7, 2016
Log # /
Registre no
2016_444602_0022 004741-16 / 018081-16
/ 024598-15 / 02459415 / 003707-16 /
004782-16 / 016295-16
/ 018621-16
Type of Inspection /
Genre d’inspection
Critical Incident
System
Licensee/Titulaire de permis
THE CORPORATION OF THE CITY OF KINGSTON
216 Ontario Street KINGSTON ON K7L 2Z3
Long-Term Care Home/Foyer de soins de longue durée
RIDEAUCREST HOME
175 RIDEAU STREET KINGSTON ON K7K 3H6
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
WENDY BROWN (602)
Inspection Summary/Résumé de l’inspection
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119
Exhibit C
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
The purpose of this inspection was to conduct a Critical Incident System
inspection.
This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016
The Medication IP was used to inspect eight (8) medication related critical incidents
as follows:
Log #004741-16 - Medication error
Log #018081-16 - Medication missing
Log #018621-16 - Medication missing
Log #016295-16 - Medication missing
Log #004782-16 - Medication missing
Log #003707-16 - Medication missing
Log #024594-15 - Medication missing
Log #024598-15 - Medication missing
During the course of the inspection, the inspector(s) spoke with Residents,
Personal Support Workers, (PSW)/Health Care Aides (HCA), Registered Practical
Nurses (RPN), Registered Nurses (RN), the Assistant Directors of Care (ADOC), the
Director of Care, and the Administrator.
The inspector(s) observed various medication passes, medication cart(s) and other
drug storage areas. Additionally medication administration, drug destruction
practices, pharmacy provider process(es), the home’s investigation documentation
and relevant policies and procedures were reviewed.
The following Inspection Protocols were used during this inspection:
Medication
During the course of this inspection, Non-Compliances were issued.
1 WN(s)
1 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
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120
Legend
Exhibit C
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
Page 3 of/de 5
121
Exhibit C
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
WN #1: The Licensee has failed to comply with O.Reg 79/10, s. 131. Administration
of drugs
Specifically failed to comply with the following:
s. 131. (1) Every licensee of a long-term care home shall ensure that no drug is
used by or administered to a resident in the home unless the drug has been
prescribed for the resident. O. Reg. 79/10, s. 131 (1).
Findings/Faits saillants :
1. The licensee has failed to ensure that no drug is used by or administered to a resident
in the home unless the drug has been prescribed for the resident.
The following finding relates to log# 004741-16:
Resident 001 was ordered a specific medication, however, on a specified date resident
001 was administered a different medication. The error was noted and the resident was
assessed and sent to hospital. The resident returned to the home with no ill effects.
Involved staff were provided medication administration training.
Additional Required Actions:
VPC - pursuant to the Long-Term Care Homes Act, 2007, S.O. 2007, c.8, s.152(2)
the licensee is hereby requested to prepare a written plan of correction for
achieving compliance to ensure that no drug is administered to a resident in the
home unless the drug has been prescribed for the resident, to be implemented
voluntarily.
Page 4 of/de 5
122
Issued on this
7th
Exhibit C
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
day of July, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 5 of/de 5
123
Exhibit D
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
Ottawa Service Area Office
347 Preston St Suite 420
OTTAWA ON K1S 3J4
Telephone: (613) 569-5602
Facsimile: (613) 569-9670
Bureau régional de services d’Ottawa
347 rue Preston bureau 420
OTTAWA ON K1S 3J4
Téléphone: (613) 569-5602
Télécopieur: (613) 569-9670
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Jul 7, 2016
Log # /
Type of Inspection /
Registre no
Genre d’inspection
2016_444602_0023 013268-16 / 014802-16 Critical Incident
System
Licensee/Titulaire de permis
THE CORPORATION OF THE CITY OF KINGSTON
216 Ontario Street KINGSTON ON K7L 2Z3
Long-Term Care Home/Foyer de soins de longue durée
RIDEAUCREST HOME
175 RIDEAU STREET KINGSTON ON K7K 3H6
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
WENDY BROWN (602)
Inspection Summary/Résumé de l’inspection
Page 1 of/de 3
124
Exhibit D
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
The purpose of this inspection was to conduct a Critical Incident System
inspection.
This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016.
Critical incident log# 013268-16 concerned alleged resident to resident sexual
abuse.
Critical Incident log# 014802-16 concerned alleged staff to resident abuse/neglect.
During the course of the inspection, the inspector(s) spoke with residents,
Personal Support Workers, (PSW) /Health Care Aides (HCA), Registered Practical
Nurses (RPN), Registered Nurses (RN), the Assistant Directors of Care (ADOC), the
Director of Care, and the Administrator.
The inspector reviewed resident health records, interviewed staff, observed
resident-resident & resident-staff interactions, as well as reviewed the Home's
investigation documentation and relevant policies and procedures. Multiple
observations of care and service delivery throughout the home were also
completed as part of the inspection.
The following Inspection Protocols were used during this inspection:
Prevention of Abuse, Neglect and Retaliation
Responsive Behaviours
During the course of this inspection, Non-Compliances were not issued.
0 WN(s)
0 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
Page 2 of/de 3
125
Legend
Exhibit D
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
Issued on this
7th
day of July, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 3 of/de 3
126
Exhibit E
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
Long-Term Care Homes Division
Long-Term Care Inspections Branch
Division des foyers de soins de
longue durée
Inspection de soins de longue durée
Ottawa Service Area Office
347 Preston St Suite 420
OTTAWA ON K1S 3J4
Telephone: (613) 569-5602
Facsimile: (613) 569-9670
Bureau régional de services d’Ottawa
347 rue Preston bureau 420
OTTAWA ON K1S 3J4
Téléphone: (613) 569-5602
Télécopieur: (613) 569-9670
Public Copy/Copie du public
Report Date(s) /
Inspection No /
Date(s) du apport No de l’inspection
Jul 7, 2016
Log # /
Registre no
2016_444602_0024 012431-16
Type of Inspection /
Genre d’inspection
Complaint
Licensee/Titulaire de permis
THE CORPORATION OF THE CITY OF KINGSTON
216 Ontario Street KINGSTON ON K7L 2Z3
Long-Term Care Home/Foyer de soins de longue durée
RIDEAUCREST HOME
175 RIDEAU STREET KINGSTON ON K7K 3H6
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
WENDY BROWN (602)
Inspection Summary/Résumé de l’inspection
Page 1 of/de 3
127
Exhibit E
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
The purpose of this inspection was to conduct a Complaint inspection.
This inspection was conducted on the following date(s): June 24, 27-30 and July 46, 2016
The complaint, identified as log#012431-16 regarded various care concerns, meal
planning and food quality
During the course of the inspection, the inspector(s) spoke with Residents,
Personal Support Workers, (PSW)/Health Care Aides (HCA), Registered Practical
Nurses (RPN), Registered Nurses (RN), the Dietary Supervisor, Life Enrichment
staff, the Assistant Directors of Care (ADOC), the Director of Care, and the
Administrator.
The following Inspection Protocols were used during this inspection:
Nutrition and Hydration
Personal Support Services
During the course of this inspection, Non-Compliances were not issued.
0 WN(s)
0 VPC(s)
0 CO(s)
0 DR(s)
0 WAO(s)
Page 2 of/de 3
128
Legend
Exhibit E
Ministry of Health and
Long-Term Care
Ministère de la Santé et des
Soins de longue durée
Inspection Report under
the Long-Term Care
Homes Act, 2007
Rapport d’inspection sous la
Loi de 2007 sur les foyers de
soins de longue durée
NON-COMPLIANCE / NON - RESPECT DES EXIGENCES
Legendé
WN – Written Notification
VPC – Voluntary Plan of Correction
DR – Director Referral
CO – Compliance Order
WAO – Work and Activity Order
WN – Avis écrit
VPC – Plan de redressement volontaire
DR – Aiguillage au directeur
CO – Ordre de conformité
WAO – Ordres : travaux et activités
Non-compliance with requirements under
the Long-Term Care Homes Act, 2007
(LTCHA) was found. (a requirement under
the LTCHA includes the requirements
contained in the items listed in the definition
of "requirement under this Act" in
subsection 2(1) of the LTCHA).
Le non-respect des exigences de la Loi de
2007 sur les foyers de soins de longue
durée (LFSLD) a été constaté. (une
exigence de la loi comprend les exigences
qui font partie des éléments énumérés dans
la définition de « exigence prévue par la
présente loi », au paragraphe 2(1) de la
LFSLD.
The following constitutes written notification Ce qui suit constitue un avis écrit de nonof non-compliance under paragraph 1 of
respect aux termes du paragraphe 1 de
section 152 of the LTCHA.
l’article 152 de la LFSLD.
Issued on this
7th
day of July, 2016
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Original report signed by the inspector.
Page 3 of/de 3
129
130
131
132
Exhibit G
Reporting Jan - Mar - Q4 2015
Facility
Q4 2015/16 CIHI
Indicator
2014 Q4
2014 Q1
2015 Q2
2015 Q3
2015 Q4
Rideaucrest
Daily physical restraints
9.8%
9.5%
8.9%
8.9%
8.6%
Province
Daily physical restraints
7.4%
7.1%
6.7%
6.3%
6.0%
SE LHIN
Daily physical restraints
12.6%
12.5%
12.2%
11.9%
11.3%
Rideaucrest
Has a stage 2-4 pressure ulcer
4.6%
4.3%
5.5%
6.1%
7.3%
Province
Has a stage 2-4 pressure ulcer
6.3%
6.2%
6.2%
6.1%
5.9%
SE LHIN
Has a stage 2-4 pressure ulcer
5.9%
5.7%
5.4%
5.4%
5.5%
Rideaucrest
Has fallen
20.3%
21.5%
20.6%
18.9%
19.5%
Province
Has fallen
14.7%
14.7%
14.8%
15.0%
15.2%
SE LHIN
Has fallen
15.2%
15.7%
16.0%
16.2%
16.4%
Rideaucrest
Taken antipsychotics without diagnosis of psychosis
27.4%
26.2%
26.0%
26.2%
24.5%
Province
Taken antipsychotics without diagnosis of psychosis
27.4%
26.4%
25.3%
24.2%
23.0%
SE LHIN
Taken antipsychotics without diagnosis of psychosis
28.1%
26.8%
25.6%
24.4%
23.3%
Rideaucrest
Worstened bladder continence
9.8%
11.5%
13.5%
18.2%
20.4%
Province
Worstened bladder continence
18.4%
18.2%
17.9%
17.6%
17.4%
SE LHIN
Worstened bladder continence
16.0%
16.2%
17.1%
17.3%
18.0%
Rideaucrest
At Least 1 Emergency Room visit
Rideaucrest
At Least 1 Hospital Stay
133
7
4
7
12
8
15
10
9
11
13

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