of the Inspector Jul 23, 2014 - Search Selections for Long

Transcription

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
Health System Accountability and
Performance Division
Performance Improvement and
Compliance Branch
Hamilton Service Area Office
119 King Street West, 11th Floor
HAMILTON, ON, L8P-4Y7
Telephone: (905) 546-8294
Facsimile: (905) 546-8255
Division de la responsabilisation et de la
performance du système de santé
Direction de l'amélioration de la
performance et de la conformité
Bureau régional de services de
Hamilton
119, rue King Ouest, 11iém étage
HAMILTON, ON, L8P-4Y7
Téléphone: (905) 546-8294
Télécopieur: (905) 546-8255
Public Copy/Copie du public
Report Date(s) /
Date(s) du Rapport
Jul 23, 2014
Inspection No /
No de l’inspection
2014_275536_0016
Log # /
Registre no
H-00081214
Type of Inspection /
Genre d’inspection
Resident Quality
Inspection
Licensee/Titulaire de permis
THE CENTRAL CANADIAN DISTRICT OF THE CHRISTIAN AND MISSIONARY
ALLIANCE IN CANADA
155 PANIN ROAD, BURLINGTON, ON, L7P-5A6
Long-Term Care Home/Foyer de soins de longue durée
ST OLGA'S LIFECARE CENTRE
570 KING STREET WEST, HAMILTON, ON, L8P-1C2
Name of Inspector(s)/Nom de l’inspecteur ou des inspecteurs
CATHIE ROBITAILLE (536), JESSICA PALADINO (586), LESLEY EDWARDS (506),
MARILYN TONE (167)
Inspection Summary/Résumé de l’inspection
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The purpose of this inspection was to conduct a Resident Quality Inspection
inspection.
This inspection was conducted on the following date(s): July 3, 4, 8, 9 and 10,
2014
The following Critical Incident Inspection was completed concurrently with the
RQI-H-000646-14.
During the course of the inspection, the inspector(s) spoke with regulated and
unregulated workers, Registered Staff, dietary staff, Nutritional Manager,
Dietitian, Activation Manager, Director of Care and the Administrator.
During the course of the inspection, the inspector(s) toured the home, observed
care and services, interviewed staff, managers,residents and families, reviewed
clinical records and relevant policies and procedures.
The following Inspection Protocols were used during this inspection:
Admission and Discharge
Continence Care and Bowel Management
Dignity, Choice and Privacy
Dining Observation
Falls Prevention
Family Council
Food Quality
Hospitalization and Change in Condition
Infection Prevention and Control
Medication
Nutrition and Hydration
Personal Support Services
Prevention of Abuse, Neglect and Retaliation
Residents' Council
Responsive Behaviours
Skin and Wound Care
Sufficient Staffing
Findings of Non-Compliance were found during this inspection.
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Legend
Long-Term Care
the Long-Term Care
Homes Act, 2007
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
Ce qui suit constitue un avis écrit de nonnotification of non-compliance under
respect aux termes du paragraphe 1 de
paragraph 1 of section 152 of the LTCHA. l’article 152 de la LFSLD.
WN #1: The Licensee has failed to comply with O.Reg 79/10, s. 73. Dining and
snack service
Specifically failed to comply with the following:
s. 73. (1) Every licensee of a long-term care home shall ensure that the home
has a dining and snack service that includes, at a minimum, the following
elements:
6. Food and fluids being served at a temperature that is both safe and palatable
to the residents. O. Reg. 79/10, s. 73 (1).
Findings/Faits saillants :
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1. The licensee did not ensure that foods and fluids were being served at safe and
palatable temperatures:
A) The home’s food temperature log indicated that hot foods must be served at a
minimum of 60°C and cold foods at a maximum of 5°C. Temperatures were taken
nearing the end of lunch service on July 9, 2014. The temperatures of the probed
items were as follows: roast beef 11.3°C, minced roast beef 12.3°C, minced broccoli
salad 9.7°C, pureed broccoli salad 10.1°C, coleslaw 12.1°C, and minced coleslaw
10°C. Temperatures were taken again during lunch service on July 10, 2014, and they
were as follows: minced chili 54.8°C, pureed cornbread 45.8°C, pureed bread 12°C,
pureed tuna salad 11.4°C, minced cucumber salad 11.3°C, and carrot salad 11.3°C.
B) During resident interviews on July 3 and 4, 2014, several residents complained that
their meals were often served cold when they should be hot. Review of the Resident’s
Council minutes from the past several months verified these concerns by residents. [s.
73. (1) 6.]
Additional Required Actions:
CO # - 001 will be served on the licensee. Refer to the “Order(s) of the
Inspector”.
WN #2: The Licensee has failed to comply with O.Reg 79/10, s. 72. Food
production
s. 72. (2) The food production system must, at a minimum, provide for,
(c) standardized recipes and production sheets for all menus; O. Reg. 79/10, s.
72 (2).
s. 72. (3) The licensee shall ensure that all food and fluids in the food
production system are prepared, stored, and served using methods to,
(a) preserve taste, nutritive value, appearance and food quality; and O. Reg.
79/10, s. 72 (3).
1. 1. The licensee did not ensure that food production system included standardized
recipes for all menus:
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A) On July 10, 2014, observation of noon meal production and the staff interviewed
confirmed that the recipe for the cucumber salad was tailored for an outsourced
product rather than a homemade dish. The recipe stated that the salad should be
served accordingly, without any further instruction, therefore did not provide clear
direction to the staff. The cook confirmed the recipe was inappropriate and therefore
made the dish without a recipe.
B) The recipes for French onion soup, garden vegetable soup, and cream of tomato
soup indicated preparation of the items on site using fresh ingredients, however staff
confirmed that all soups, excepting stews, are outsource and are not prepared in the
home.
C) The recipe for the southwestern turkey chili had handwritten adjustments crossing
out the original instructions and directing the cook to use vegetarian chili and add
cooked ground turkey, rather than make the chili from scratch. There were no
measurements for how much vegetarian chili to use, and no instructions for the
preparation. The recipe was not appropriately adjusted for changes in procedure. [s.
72. (2) (c)]
2. The licensee did not ensure that all food and fluids in the food production system
were prepared, stored, and served using methods to preserve taste, nutritive value,
appearance and food quality:
A) On June 9, 2014, the recipes for pureed pecan streusel and pureed fresh fruit were
not followed. The recipe for the pureed pecan streusel stated that the cook was to
add the cake and 2% milk to a food processor and blend. Interview with the dietary
aide preparing the dessert confirmed that only water was added to the cake and
processed. The recipe for the pureed fresh fruit stated that the cook was to add the
fruit and thickener to a food processor and blend. Interview with the dietary aide who
prepared the dessert confirmed that orange juice was added to the fruit and that
thickener was not used. The taste, nutritive value and food quality of the food items
was compromised.
B) On July 10, 2014, the recipes for pineapple vanilla parfait (diet and pureed), pureed
cucumber salad and soaked cornbread were not followed. The recipe for diet
pineapple vanilla parfait called for the same measurements as the regular parfait,
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however diet pudding was to be used. The staff preparing the item stated that for the
diet version, regular pudding was used, and that the residents just receive a smaller
scoop size. The recipe for the pureed parfait called for cake, pudding and whipped
topping to be blended. Staff interview and observation confirmed no whip topping was
included. The recipe for the pureed cucumber salad called for thickener. Observation
confirmed no thickener was used. The recipe for the soaked cornbread called for the
bread to be soaked in milk. Observation confirmed the bread was soaked in water.
The taste, nutritive value and food quality of the food items was compromised.
C) Dietary staff were observed preparing pureed vanilla pineapple puree without
weighing or measuring the components listed in the recipe. Staff were also observed
preparing pureed peaches by pouring thickener into the food processor straight from
the container without using appropriate measurements, affecting the taste,
appearance and food quality.
D) During lunch service on July 11, 2014, a staff was observed using thickener to
thicken a resident’s soup in front of them at their table. The staff was observed adding
several scoops of the thickener to the soup without using proper measurements.
They were unable to verify how much thickener should be used for a honey-thick
product. As a result, the resident was observed being fed soup that had large visible
clumps of thickener in it. The taste, appearance and food quality was compromised.
E) On July 9 and 10, 2014, the lunch meal served to residents was visually
unappealing. Resident #021 was served three thin slices of beef in the center of a
large plate. The resident, along with resident #015, complained about the appearance
of the meal, stating the plating was unappetizing. The pineapple vanilla parfait recipe
stated it was to be served in dessert glasses or bowls, however it was served on
plates. The pudding was running all over the plates. Additionally, the plates edges
were stacked to fit on one serving tray, therefore several of the plates had dessert all
over the edges, affecting the appearance of the food. [s. 72. (3) (a)]
CO # - 002, 003 will be served on the licensee. Refer to the “Order(s) of the
Inspector”.
WN #3: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 3.
Residents’ Bill of Rights
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s. 3. (1) Every licensee of a long-term care home shall ensure that the following
rights of residents are fully respected and promoted:
19. Every resident has the right to have his or her lifestyle and choices
respected. 2007, c. 8, s. 3 (1).
1. The licensee did not ensure that every resident had his or her choices respected:
During multiple interviews between July 4 – 10, 2014, resident #015 stated that they
highly disliked cream of wheat, but enjoyed porridge for breakfast. Approximately two
weeks ago, the resident stated that when they asked if they could have porridge every
morning, they were told by a dietary worker that they could not have oatmeal on the
days that cream of wheat was served, and that they must eat the cream of wheat.
Interview with dietary staff and the Nutrition Manager confirmed that they prepare
special items for several other residents each day based on preferences and
requests. The resident also stated they have often gone without eating because they
received cream of wheat, and as a consequence has lost weight in the last few
months. Review of the resident’s monthly weight records confirmed this. The resident
told the inspector that would eat porridge every morning if they were served it. The
resident’s food choices were not respected. [s. 3. (1) 19.]
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 and ensuring that the resident has his or her choices
respected, to be implemented voluntarily.
WN #4: The Licensee has failed to comply with O.Reg 79/10, s. 26. Plan of care
s. 26. (3) A plan of care must be based on, at a minimum, interdisciplinary
assessment of the following with respect to the resident:
12. Dental and oral status, including oral hygiene. O. Reg. 79/10, s. 26 (3).
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1. The plan of care for resident #008 was not based on an assessment of the
resident’s dental and oral status:
The Minimum Data Set (MDS) assessment for resident #008 dated as completed on
May 23, 2014, indicated that the resident required daily cleaning of teeth or dentures
or daily mouth care - by resident or staff, but did not indicate that the resident was
edentulous.
- It was noted during observation of the resident and confirmed by staff that the
resident has no teeth.
- The resident confirmed during an interview that they have upper and lower dentures
but choose not to wear them.
- During a review of the document that the home refers to as the care plan, it was
noted that the care plan did not identify the resident’s oral status or whether or not
they in fact, had any teeth/dentures or choose not to wear the dentures. [s. 26. (3) 12.]
2. The plan of care for resident #006 was not based on an assessment of the
resident’s dental and oral status:
A review of the resident’s MDS assessment dated May 26, 2014 stated the resident
required daily cleaning of teeth or dentures.
- A review of the resident’s most current care plan and kardex demonstrated that there
was no mention of the resident's oral care needs. The care plan did not identify the
residents oral status to indicate that the resident had natural teeth. The Director of
Care (DOC) confirmed that this information should be identified in the resident’s care
plan or kardex. [s. 26. (3) 12.]
achieving compliance and ensuring that the plan of care is based on an
assessment, to be implemented voluntarily.
WN #5: The Licensee has failed to comply with O.Reg 79/10, s. 48. Required
programs
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s. 48. (1) Every licensee of a long-term care home shall ensure that the
following interdisciplinary programs are developed and implemented in the
home:
1. A falls prevention and management program to reduce the incidence of falls
and the risk of injury. O. Reg. 79/10, s. 48 (1).
2. A skin and wound care program to promote skin integrity, prevent the
development of wounds and pressure ulcers, and provide effective skin and
wound care interventions. O. Reg. 79/10, s. 48 (1).
3. A continence care and bowel management program to promote continence
and to ensure that residents are clean, dry and comfortable. O. Reg. 79/10, s. 48
(1).
4. A pain management program to identify pain in residents and manage pain.
O. Reg. 79/10, s. 48 (1).
1. The licensee did not ensure that the home’s policy related to Falls Prevention and
Management was implemented within the home:
The Home’s policy related to Falls Prevention and Management ( Policy #08-14-01
with last revision date of February 2004) directs staff to complete a Fall Risk
Assessment on admission, quarterly and when a significant change in health status
occurs.
The DOC confirmed that staff are currently expected to complete a Falls Risk
Assessment on admission, quarterly and with a significant change in condition.
A) Resident #001 was noted to have sustained five falls over the past year. It was
noted that no Fall Risk Assessments had been completed by staff at the home since
January 2014, when the resident was noted to be a moderate risk for falls.
B) Resident #008 was noted to have experienced 10 falls over the past year. It was
noted that no Fall Risk Assessment had been completed for the resident since
January 2014 when the resident was noted to be a moderate risk for falls. [s. 48. (1)
1.]
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achieving compliance and ensuring the the home's policy related to Falls
Prevention and Management is implemented, to be implemented voluntarily.
WN #6: The Licensee has failed to comply with O.Reg 79/10, s. 229. Infection
prevention and control program
s. 229. (4) The licensee shall ensure that all staff participate in the
implementation of the program. O. Reg. 79/10, s. 229 (4).
s. 229. (10) The licensee shall ensure that the following immunization and
screening measures are in place:
3. Residents must be offered immunizations against pneumoccocus, tetanus
and diphtheria in accordance with the publicly funded immunization schedules
posted on the Ministry website. O. Reg. 79/10, s. 229 (10).
1. The licensee did not ensure that staff participated in the implementation of the
infection prevention and control program related to storage of residents' personal care
equipment:
During observation of residents' bathrooms on July 4, 2014, the following concerns
were noted:
i) In room 301, there were six unlabeled tooth brushes and two unlabeled bars of soap
on the counter in the bathroom shared by four residents.
ii) In room 302, there was no label on the denture cup on the counter in the bathroom
shared by four residents and there was one tooth brush found standing upright inside
of a toilet tissue roll on the bathroom counter. This toothbrush was not labeled.
iii) In room 303, there was an unlabeled toothbrush standing upright inside a toilet
paper roll and an unlabeled denture cup on the counter in the shared bathroom.
During an interview with the Director of Care (DOC), it was confirmed that all personal
care equipment belonging to residents are to be labeled and stored appropriately. [s.
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229. (4)]
2. The licensee did not ensure that staff participated in the implementation of the
infection prevention and control program related to hand hygiene:
During the lunch meal service on July 3, 2014, a health care aide (HCA) was
observed clearing dirty dishes, then proceeded to serve residents without having
washed their hands. Another HCA was observed clearing dirty dishes and then
continued to assist a resident with feeding without having washed their hands. [s. 229.
(4)]
3. The licensee did not ensure that residents were offered immunization against
tetanus and diphtheria in accordance with publicly funded immunization schedules:
During a review of the immunization records for five residents at the home, it was
noted that the residents had not received or been offered immunization against
tetanus and diphtheria.
During an interview with the DOC, it was confirmed that the home had recently
collected the immunization history related to tetanus and diphtheria for residents at the
home.
The DOC indicated the tetanus and diptheria vaccine has been received from public
health, but residents at the home have not yet received their immunization. [s. 229.
(10) 3.]
achieving compliance and ensuring that staff participate in the infection
prevention and control program, to be implemented voluntarily.
WN #7: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s. 6.
Plan of care
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s. 6. (4) The licensee shall ensure that the staff and others involved in the
different aspects of care of the resident collaborate with each other,
(a) in the assessment of the resident so that their assessments are integrated
and are consistent with and complement each other; and 2007, c. 8, s. 6 (4).
(b) in the development and implementation of the plan of care so that the
different aspects of care are integrated and are consistent with and complement
each other. 2007, c. 8, s. 6 (4).
1. The licensee did not ensure that staff collaborated in the development and
implementation of the residents’ plans of care:
A) During lunch service on July 4, 2014, resident #011 received their soup in a mug
and a lipped plate. Interview with the HCA confirmed that the resident received these
assistive devices due to personal preference and to support the resident with feeding
themself. The use of a mug for soup and a lipped plate at meals were not included in
the resident’s diet list, which is used to keep staff aware of the resident’s specific
needs during dining, or the resident’s plan of care.
B) During lunch service on July 4, 2014, resident #020 received their soup in a mug.
Interview with the HCA confirmed that the resident preferred their soup in a mug to aid
in feeding themselves. This was not included in the resident’s plan of care or diet list.
The frontline staff and RD did not collaborate in the development and implementation
of the residents’ plans of care. [s. 6. (4) (b)]
WN #8: The Licensee has failed to comply with LTCHA, 2007 S.O. 2007, c.8, s.
57. Powers of Residents’ Council
s. 57. (2) If the Residents’ Council has advised the licensee of concerns or
recommendations under either paragraph 6 or 8 of subsection (1), the licensee
shall, within 10 days of receiving the advice, respond to the Residents’ Council
in writing. 2007, c. 8, s. 57.(2).
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1. The licensee did not respond in writing within ten days of receiving Residents’
Council advice related to concerns or recommendations:
A) There was no record to indicate that all recommendations made by the council
regarding concerns were responded to in writing within the ten days or responded to
at all. The Activity Manager confirmed that the council was not always responded to
within the ten days and at times there was no response made to the council at all. [s.
57. (2)]
78. Information for residents, etc.
s. 78. (2) The package of information shall include, at a minimum,
(a) the Residents’ Bill of Rights; 2007, c. 8, s. 78 (2)
(b) the long-term care home’s mission statement; 2007, c. 8, s. 78 (2)
(c) the long-term care home’s policy to promote zero tolerance of abuse and
neglect of residents; 2007, c. 8, s. 78 (2)
(d) an explanation of the duty under section 24 to make mandatory reports;
2007, c. 8, s. 78 (2)
(e) the long-term care home’s procedure for initiating complaints to the
licensee; 2007, c. 8, s. 78 (2)
(f) the written procedure, provided by the Director, for making complaints to the
Director, together with the name and telephone number of the Director, or the
name and telephone number of a person designated by the Director to receive
complaints; 2007, c. 8, s. 78 (2)
(g) notification of the long-term care home’s policy to minimize the restraining
of residents and how a copy of the policy can be obtained; 2007, c. 8, s. 78 (2)
(h) the name and telephone number of the licensee; 2007, c. 8, s. 78 (2)
(i) a statement of the maximum amount that a resident can be charged under
paragraph 1 or 2 of subsection 91 (1) for each type of accommodation offered in
the long-term care home; 2007, c. 8, s. 78 (2)
(j) a statement of the reductions, available under the regulations, in the amount
that qualified residents can be charged for each type of accommodation offered
in the long-term care home; 2007, c. 8, s. 78 (2)
(k) information about what is paid for by funding under this Act or the Local
Health System Integration Act, 2006 or the payments that residents make for
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accommodation and for which residents do not have to pay additional charges;
2007, c. 8, s. 78 (2)
(l) a list of what is available in the long-term care home for an extra charge, and
the amount of the extra charge; 2007, c. 8, s. 78 (2)
(m) a statement that residents are not required to purchase care, services,
programs or goods from the licensee and may purchase such things from other
providers, subject to any restrictions by the licensee, under the regulations,
with respect to the supply of drugs; 2007, c. 8, s. 78 (2)
(n) a disclosure of any non-arm’s length relationships that exist between the
licensee and other providers who may offer care, services, programs or goods
to residents; 2007, c. 8, s. 78 (2)
(o) information about the Residents’ Council, including any information that
may be provided by the Residents’ Council for inclusion in the package; 2007,
c. 8, s. 78 (2)
(p) information about the Family Council, if any, including any information that
may be provided by the Family Council for inclusion in the package, or, if there
is no Family Council, any information provided for in the regulations; 2007, c. 8,
s. 78 (2)
(q) an explanation of the protections afforded by section 26; 2007, c. 8, s. 78 (2)
(r) any other information provided for in the regulations. 2007, c. 8, s. 78 (2)
1. The licensee did not ensure that the admission package included the telephone
number of the licensee:
Review of the resident admission package identified that it did not include the
telephone number of the licensee. This was confirmed on July 10, 2014 by the
Administrator. [s. 78. (2) (h)]
2. The licensee did not ensure that the admission package included information about
the Family Council:
Review of the resident admission package identified that it did not include any
information about Family Council. This was confirmed on July 10, 2014 by the
Administrator. [s. 78. (2) (p)]
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79. Posting of information
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s. 79. (3) The required information for the purposes of subsections (1) and (2)
is,
(a) the Residents’ Bill of Rights; 2007, c. 8, s. 79 (3)
(b) the long-term care home’s mission statement; 2007, c. 8, s. 79 (3)
(c) the long-term care home’s policy to promote zero tolerance of abuse and
neglect of residents; 2007, c. 8, s. 79 (3)
(d) an explanation of the duty under section 24 to make mandatory reports;
2007, c. 8, s. 79 (3)
(e) the long-term care home’s procedure for initiating complaints to the
licensee; 2007, c. 8, s. 79 (3)
(f) the written procedure, provided by the Director, for making complaints to the
Director, together with the name and telephone number of the Director, or the
name and telephone number of a person designated by the Director to receive
complaints; 2007, c. 8, s. 79 (3)
(g) notification of the long-term care home’s policy to minimize the restraining
of residents, and how a copy of the policy can be obtained; 2007, c. 8, s. 79 (3)
(h) the name and telephone number of the licensee; 2007, c. 8, s. 79 (3)
(i) an explanation of the measures to be taken in case of fire; 2007, c. 8, s. 79
(3)
(j) an explanation of evacuation procedures; 2007, c. 8, s. 79 (3)
(k) copies of the inspection reports from the past two years for the long-term
care home; 2007, c. 8, s. 79 (3)
(l) orders made by an inspector or the Director with respect to the long-term
care home that are in effect or that have been made in the last two years; 2007,
c. 8, s. 79 (3)
(m) decisions of the Appeal Board or Divisional Court that were made under this
Act with respect to the long-term care home within the past two years; 2007, c.
8, s. 79 (3)
(n) the most recent minutes of the Residents’ Council meetings, with the
consent of the Residents’ Council; 2007, c. 8, s. 79 (3)
(o) the most recent minutes of the Family Council meetings, if any, with the
consent of the Family Council; 2007, c. 8, s. 79 (3)
(p) an explanation of the protections afforded under section 26; 2007, c. 8, s. 79
(3)
(q) any other information provided for in the regulations. 2007, c. 8, s. 79 (3)
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1. The licensee did not ensure that the policy to promote zero tolerance of abuse and
neglect of residents was posted in a conspicuous and easily accessible location:
Review of the publicly posted information in the home identified that there were no
postings on the home's policy to promote zero tolerance of abuse and neglect of
residents. This was confirmed on July 10, 2014 by the Administrator. [s. 79. (3) (c)]
2. The licensee did not ensure that the policy to minimize the restraining of residents
was posted in a conspicuous and easily accessible location:
postings on the policy to minimize the restraining of residents. This was confirmed on
July 10, 2014 by the Administrator. [s. 79. (3) (g)]
3. The licensee did not ensure that an explanation of whistle-blowing protections
related to retaliation was posted in a conspicuous and easily accessible location:
postings on the policy to minimize the restraining of residents. This was confirmed on
July 10, 2014 by the Administrator. [s. 79. (3) (p)]
85. Satisfaction survey
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Long-Term Care
the Long-Term Care
Homes Act, 2007
s. 85. (4) The licensee shall ensure that,
(a) the results of the survey are documented and made available to the
Residents’ Council and the Family Council, if any, to seek their advice under
subsection (3); 2007, c. 8, s. 85. (4).
(b) the actions taken to improve the long-term care home, and the care,
services, programs and goods based on the results of the survey are
documented and made available to the Residents’ Council and the Family
Council, if any; 2007, c. 8, s. 85. (4).
(c) the documentation required by clauses (a) and (b) is made available to
residents and their families; and 2007, c. 8, s. 85. (4).
(d) the documentation required by clauses (a) and (b) is kept in the long-term
care home and is made available during an inspection under Part IX. 2007, c. 8,
s. 85. (4).
1. The licensee did not ensure that the results of the satisfaction survey were made
available to the Residents' Council:
A satisfaction survey was completed in January 2014. Results from the satisfaction
survey were not directly communicated to the Residents' Council. This was confirmed
by the Administrator on July 10, 2014. [s. 85. (4)]
WN #12: The Licensee has failed to comply with O.Reg 79/10, s. 224.
Information for residents, etc.
s. 224. (1) For the purposes of clause 78 (2) (r) of the Act, every licensee of a
long-term care home shall ensure that the package of information provided for
in section 78 of the Act includes information about the following:
3. The obligation of the resident to pay accommodation charges during a
medical, psychiatric, vacation or casual absence as set out in section 258 of
this Regulation. O. Reg. 79/10, s. 224 (1).
Page 18 of/de 20
Long-Term Care
the Long-Term Care
Homes Act, 2007
1. The licensee did not ensure that the admission package included the resident's
obligation to pay accommodation charges during a medical, psychiatric, vacation or
casual absence from the home:
Review of the resident admission package identified that it did not include the
resident's obligation to pay accommodation charges during a medical, psychiatric,
vacation or casual absence from the home. This was confirmed on July 10, 2014 by
the Administrator. [s. 224. (1) 3.]
WN #13: The Licensee has failed to comply with O.Reg 79/10, s. 225. Posting of
information
s. 225. (1) For the purposes of clause 79 (3) (q) of the Act, every licensee of a
long-term care home shall ensure that the information required to be posted in
the home and communicated to residents under section 79 of the Act includes
the following:
1. The fundamental principle set out in section 1 of the Act. O. Reg. 79/10, s.
225 (1).
2. The home’s licence or approval, including any conditions or amendments,
other than conditions that are imposed under the regulations or the conditions
under subsection 101 (3) of the Act. O. Reg. 79/10, s. 225 (1).
3. The most recent audited report provided for in clause 243 (1) (a). O. Reg.
79/10, s. 225 (1).
4. The Ministry’s toll-free telephone number for making complaints about
homes and its hours of service. O. Reg. 79/10, s. 225 (1).
5. Together with the explanation required under clause 79 (3) (d) of the Act, the
name and contact information of the Director to whom a mandatory report shall
be made under section 24 of the Act. O. Reg. 79/10, s. 225 (1).
Page 19 of/de 20
Long-Term Care
the Long-Term Care
Homes Act, 2007
1. The licensee did not ensure that an explanation of a person's duty to make
mandatory reports to the Director was posted in the home in a conspicuous and easily
accessible location:
postings on a person's duty to make mandatory reports to the Director. This was
confirmed on July 10, 2014 by the Administrator. [s. 225. (1) 5.]
Issued on this
23rd
day of July, 2014
Signature of Inspector(s)/Signature de l’inspecteur ou des inspecteurs
Page 20 of/de 20
Health System Accountability and Performance Division
Performance Improvement and Compliance Branch
Division de la responsabilisation et de la performance du système de santé
Direction de l'amélioration de la performance et de la conformité
Public Copy/Copie du public
Name of Inspector (ID #) /
Nom de l’inspecteur (No) : CATHIE ROBITAILLE (536), JESSICA PALADINO
(586), LESLEY EDWARDS (506), MARILYN TONE
(167)
Inspection No. /
No de l’inspection :
2014_275536_0016
Log No. /
Registre no:
Type of Inspection /
Genre
d’inspection:
Report Date(s) /
Date(s) du Rapport :
Licensee /
Titulaire de permis :
LTC Home /
Foyer de SLD :
Name of Administrator /
Nom de l’administratrice
ou de l’administrateur :
Page 1 of/de 13
H-000812-14
Resident Quality Inspection
Jul 23, 2014
THE CENTRAL CANADIAN DISTRICT OF THE
CHRISTIAN AND MISSIONARY ALLIANCE IN
CANADA
155 PANIN ROAD, BURLINGTON, ON, L7P-5A6
ST OLGA'S LIFECARE CENTRE
570 KING STREET WEST, HAMILTON, ON, L8P-1C2
To THE CENTRAL CANADIAN DISTRICT OF THE CHRISTIAN AND MISSIONARY
ALLIANCE IN CANADA, you are hereby required to comply with the following order(s)
by the date(s) set out below:
Page 2 of/de 13
Order # /
Ordre no : 001
Order Type /
Genre d’ordre : Compliance Orders, s. 153. (1) (b)
Pursuant to / Aux termes de :
O.Reg 79/10, s. 73. (1) Every licensee of a long-term care home shall ensure
that the home has a dining and snack service that includes, at a minimum, the
following elements:
1. Communication of the seven-day and daily menus to residents.
2. Review, subject to compliance with subsection 71 (6), of meal and snack times
by the Residents’ Council.
3. Meal service in a congregate dining setting unless a resident’s assessed
needs indicate otherwise.
4. Monitoring of all residents during meals.
5. A process to ensure that food service workers and other staff assisting
residents are aware of the residents’ diets, special needs and preferences.
6. Food and fluids being served at a temperature that is both safe and palatable
to the residents.
7. Sufficient time for every resident to eat at his or her own pace.
8. Course by course service of meals for each resident, unless otherwise
indicated by the resident or by the resident’s assessed needs.
9. Providing residents with any eating aids, assistive devices, personal
assistance and encouragement required to safely eat and drink as comfortably
and independently as possible.
10. Proper techniques to assist residents with eating, including safe positioning
of residents who require assistance.
11. Appropriate furnishings and equipment in resident dining areas, including
comfortable dining room chairs and dining room tables at an appropriate height to
meet the needs of all residents and appropriate seating for staff who are assisting
residents to eat. O. Reg. 79/10, s. 73 (1).
Order / Ordre :
The licensee shall prepare, submit and implement a plan that outlines how the
home will ensure that all foods and fluids are served at safe and palatable
temperatures. The plan is to be submitted to Long-Term Care Homes Inspector
Jessica Paladino by July 30, 2014 at: [email protected].
Page 3 of/de 13
Grounds / Motifs :
1. A) Previously issued as a VPC in November 2013.
B) The home’s food temperature log indicated that hot foods must be served at a
minimum of 60°C and cold foods at a maximum of 5°C. Temperatures were
taken nearing the end of lunch service on July 9, 2014. The temperatures of the
probed items were as follows: roast beef 11.3°C, minced roast beef 12.3°C,
minced broccoli salad 9.7°C, pureed broccoli salad 10.1°C, coleslaw 12.1°C,
and minced coleslaw 10°C. Temperatures were taken again during lunch service
on July 10, 2014, and they were as follows: minced chili 54.8°C, pureed
cornbread 45.8°C, pureed bread 12°C, pureed tuna salad 11.4°C, minced
cucumber salad 11.3°C, and carrot salad 11.3°C.
C) During resident interviews on July 3 and 4, 2014, several residents
complained that their meals were often served cold when they should be hot.
Review of the Resident’s Council minutes from the past several months verified
these concerns by residents. (586)
This order must be complied with by /
Vous devez vous conformer à cet ordre d’ici le :
Page 4 of/de 13
Jul 30, 2014
Order # /
Ordre no : 002
Order Type /
O.Reg 79/10, s. 72. (2) The food production system must, at a minimum, provide
for,
(a) a 24-hour supply of perishable and a three-day supply of non-perishable
foods;
(b) a three-day supply of nutritional supplements, enteral or parenteral formulas
as applicable;
(c) standardized recipes and production sheets for all menus;
(d) preparation of all menu items according to the planned menu;
(e) menu substitutions that are comparable to the planned menu;
(f) communication to residents and staff of any menu substitutions; and
(g) documentation on the production sheet of any menu substitutions. O. Reg.
79/10, s. 72 (2).
Order / Ordre :
home will ensure that standardized recipes are accurate, appropriate, and
available for all menu items. The plan is to be submitted to Long-Term Care
Homes Inspector Jessica Paladino by July 30, 2014 at:
[email protected].
Grounds / Motifs :
Page 5 of/de 13
1. A) Previously issued as a VPC November 2013.
B) On July 10, 2014, observation of noon meal production and the staff
interviewed confirmed that the recipe for the cucumber salad was tailored for an
outsourced product rather than a homemade dish. The recipe stated that the
salad should be served accordingly, without any further instruction, therefore did
not provide clear direction to the staff. The cook confirmed the recipe was
inappropriate and therefore made the dish without a recipe.
C) The recipes for French onion soup, garden vegetable soup, and cream of
tomato soup indicated preparation of the items on site using fresh ingredients,
however staff confirmed that all soups, excepting stews, are outsource and are
not prepared in the home.
D) The recipe for the southwestern turkey chili was had handwritten adjustments
crossing out the original instructions and directing the cook to use vegetarian
chili and add cooked ground turkey, rather than make the chili from scratch.
There were no measurements for how much vegetarian chili to use, and no
instructions for the preparation. The recipe was not appropriately adjusted for
changes in procedure. (586)
Page 6 of/de 13
Jul 30, 2014
Order # /
Ordre no : 003
Order Type /
O.Reg 79/10, s. 72. (3) The licensee shall ensure that all food and fluids in the
food production system are prepared, stored, and served using methods to,
(a) preserve taste, nutritive value, appearance and food quality; and
(b) prevent adulteration, contamination and food borne illness. O. Reg. 79/10, s.
72 (3).
Order / Ordre :
home will ensure that foods and fluids are prepared, stored, and served using
methods to preserve taste, nutritive value, appearance and food quality.
Specifically, how the home will ensure a) All recipes are followed, including the
use of all ingredients and in correct quantities, by following the recipe's specific
instructions, b) All pureed items are served at the appropriate consistency, and
c) Meals will be plated and served in a manner that is visually appealing to
residents. The plan is to be submitted to Long-Term Care Homes Inspector
Jessica Paladino by July 30, 2014 at: [email protected].
Grounds / Motifs :
1. A) Previously issued as VPC in November 2013.
B) On June 9, 2014, the recipes for pureed pecan streusel and pureed fresh fruit
were not followed. The recipe for the pureed pecan streusel stated that the
cook was to add the cake and 2% milk to a food processor and blend. Interview
with the dietary aide preparing the dessert confirmed that only water was added
to the cake and processed. The recipe for the pureed fresh fruit stated that the
cook was to add the fruit and thickener to a food processor and blend. Interview
with the dietary aide who prepared the dessert confirmed that orange juice was
added to the fruit and that thickener was not used. The taste, nutritive value and
food quality of the food items was compromised.
C) On July 10, 2014, the recipes for pineapple vanilla parfait (diet and pureed),
pureed cucumber salad and soaked cornbread were not followed. The recipe
Page 7 of/de 13
for diet pineapple vanilla parfait called for the same measurements as the
regular parfait, however diet pudding was to be used. The staff preparing the
item stated that for the diet version, regular pudding was used, and that the
residents just receive a smaller scoop size. The recipe for the pureed parfait
called for cake, pudding and whipped topping to be blended. Staff interview and
observation confirmed no whip topping was included. The recipe for the pureed
cucumber salad called for thickener. Observation confirmed no thickener was
used. The recipe for the soaked cornbread called for the bread to be soaked in
milk. Observation confirmed the bread was soaked in water. The taste, nutritive
value and food quality of the food items was compromised.
D) Dietary staff were observed preparing pureed vanilla pineapple puree without
weighing or measuring the components listed in the recipe. Staff were also
observed preparing pureed peaches by pouring thickener into the food
processor straight from the container without using appropriate measurements,
affecting the taste, appearance and food quality.
E) During lunch service on July 11, 2014, a staff was observed using thickener
to thicken a resident’s soup in front of them at their table. The staff was
observed adding several scoops of the thickener to the soup without using
proper measurements. They were unable to verify how much thickener should
be used for a honey-thick product. As a result, the resident was observed being
fed soup that had large visible clumps of thickener in it. The taste, appearance
and food quality was compromised.
F) On July 9 and 10, 2014, the lunch meal served to residents was visually
unappealing. Resident #021 was served three thin slices of beef in the center of
a large plate. The resident, along with resident #015, complained about the
appearance of the meal, stating the plating was unappetizing. The pineapple
vanilla parfait recipe stated it was to be served in dessert glasses or bowls,
however it was served on plates. The pudding was running all over the plates.
Additionally, the plates edges were stacked to fit on one serving tray, therefore
several of the plates had dessert all over the edges, affecting the appearance of
the food. (586)
Page 8 of/de 13
Page 9 of/de 13
Jul 30, 2014
REVIEW/APPEAL INFORMATION
TAKE NOTICE:
The Licensee has the right to request a review by the Director of this (these) Order(s)
and to request that the Director stay this (these) Order(s) in accordance with section
163 of the Long-Term Care Homes Act, 2007.
The request for review by the Director must be made in writing and be served on the
Director within 28 days from the day the order was served on the Licensee.
The written request for review must include,
(a) the portions of the order in respect of which the review is requested;
(b) any submissions that the Licensee wishes the Director to consider; and
(c) an address for services for the Licensee.
The written request for review must be served personally, by registered mail or by fax
upon:
Director
c/o Appeals Coordinator
Performance Improvement and Compliance Branch
Ministry of Health and Long-Term Care
1075 Bay Street, 11th Floor
TORONTO, ON
M5S-2B1
Fax: 416-327-7603
Page 10 of/de 13
When service is made by registered mail, it is deemed to be made on the fifth day
after the day of mailing and when service is made by fax, it is deemed to be made on
the first business day after the day the fax is sent. If the Licensee is not served with
written notice of the Director's decision within 28 days of receipt of the Licensee's
request for review, this(these) Order(s) is(are) deemed to be confirmed by the Director
and the Licensee is deemed to have been served with a copy of that decision on the
expiry of the 28 day period.
The Licensee has the right to appeal the Director's decision on a request for review of
an Inspector's Order(s) to the Health Services Appeal and Review Board (HSARB) in
accordance with section 164 of the Long-Term Care Homes Act, 2007. The HSARB is
an independent tribunal not connected with the Ministry. They are established by
legislation to review matters concerning health care services. If the Licensee decides
to request a hearing, the Licensee must, within 28 days of being served with the
notice of the Director's decision, give a written notice of appeal to both:
Health Services Appeal and Review Board and the Director
Attention Registrar
151 Bloor Street West
9th Floor
Toronto, ON M5S 2T5
Director
c/o Appeals Coordinator
Performance Improvement and Compliance
Branch
Ministry of Health and Long-Term Care
1075 Bay Street, 11th Floor
TORONTO, ON
M5S-2B1
Fax: 416-327-7603
Upon receipt, the HSARB will acknowledge your notice of appeal and will provide
instructions regarding the appeal process. The Licensee may learn
more about the HSARB on the website www.hsarb.on.ca.
Page 11 of/de 13
RENSEIGNEMENTS SUR LE RÉEXAMEN/L’APPEL
PRENDRE AVIS
En vertu de l’article 163 de la Loi de 2007 sur les foyers de soins de longue durée, le
titulaire de permis peut demander au directeur de réexaminer l’ordre ou les ordres
qu’il a donné et d’en suspendre l’exécution.
La demande de réexamen doit être présentée par écrit et est signifiée au directeur
dans les 28 jours qui suivent la signification de l’ordre au titulaire de permis.
La demande de réexamen doit contenir ce qui suit :
a) les parties de l’ordre qui font l’objet de la demande de réexamen;
b) les observations que le titulaire de permis souhaite que le directeur examine;
c) l’adresse du titulaire de permis aux fins de signification.
La demande écrite est signifiée en personne ou envoyée par courrier recommandé ou
par télécopieur au:
Directeur
a/s Coordinateur des appels
Direction de l’amélioration de la performance et de la conformité
Ministère de la Santé et des Soins de longue durée
1075, rue Bay, 11e étage
Ontario, ON
M5S-2B1
Fax: 416-327-7603
Les demandes envoyées par courrier recommandé sont réputées avoir été signifiées
le cinquième jour suivant l’envoi et, en cas de transmission par télécopieur, la
signification est réputée faite le jour ouvrable suivant l’envoi. Si le titulaire de permis
ne reçoit pas d’avis écrit de la décision du directeur dans les 28 jours suivant la
signification de la demande de réexamen, l’ordre ou les ordres sont réputés confirmés
par le directeur. Dans ce cas, le titulaire de permis est réputé avoir reçu une copie de
la décision avant l’expiration du délai de 28 jours.
Page 12 of/de 13
En vertu de l’article 164 de la Loi de 2007 sur les foyers de soins de longue durée, le
titulaire de permis a le droit d’interjeter appel, auprès de la Commission d’appel et de
révision des services de santé, de la décision rendue par le directeur au sujet d’une
demande de réexamen d’un ordre ou d’ordres donnés par un inspecteur. La
Commission est un tribunal indépendant du ministère. Il a été établi en vertu de la loi
et il a pour mandat de trancher des litiges concernant les services de santé. Le
titulaire de permis qui décide de demander une audience doit, dans les 28 jours qui
suivent celui où lui a été signifié l’avis de décision du directeur, faire parvenir un avis
d’appel écrit aux deux endroits suivants :
À l’attention du registraire
Commission d’appel et de révision
des services de santé
151, rue Bloor Ouest, 9e étage
Toronto (Ontario) M5S 2T5
Directeur
a/s Coordinateur des appels
Direction de l’amélioration de la performance et de la
conformité
Ministère de la Santé et des Soins de longue durée
1075, rue Bay, 11e étage
Ontario, ON
M5S-2B1
Fax: 416-327-7603
La Commission accusera réception des avis d’appel et transmettra des instructions
sur la façon de procéder pour interjeter appel. Les titulaires de permis peuvent se
renseigner sur la Commission d’appel et de révision des services de santé en
consultant son site Web, au www.hsarb.on.ca.
Issued on this
23rd
day of July, 2014
Signature of Inspector /
Signature de l’inspecteur :
Name of Inspector /
Nom de l’inspecteur :
Cathie Robitaille
Service Area Office /
Bureau régional de services : Hamilton Service Area Office
Page 13 of/de 13

of the Inspector Jul 23, 2014 - Search Selections for Long

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