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1 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 Ottawa Service Area Office 347 Preston St, 4th Floor OTTAWA, ON, L1K-0E1 Telephone: (613) Facsimile: (613) Bureau régional de services d Ottawa 347, rue Preston, 4iém étage OTTAWA, ON, L1K-0E1 Téléphone: (613) Télécopieur: (613) Report Date(s) / Date(s) du Rapport Oct 10, 2014 Inspection No / No de l inspection 2014_294555_0022 Public Copy/Copie du public Log # / Registre no O Type of Inspection / Genre d inspection Critical Incident System Licensee/Titulaire de permis Glen Hill Terrace Christian Homes Inc. 200 Glen Hill Drive South, WHITBY, ON, L1N-9W2 Home/Foyer de MARNWOOD LIFECARE CENTRE 26 Elgin Street, Bowmanville, ON, L1C-3C8 Name of Inspector(s)/Nom de l inspecteur ou des inspecteurs GWEN COLES (555) Inspection Summary/Résumé de l inspection Page 1 of/de 6

2 The purpose of this inspection was to conduct a Critical Incident System inspection. This inspection was conducted on the following date(s): September 4 and This inspection was related to Log #O During the course of the inspection, the inspector(s) spoke with the Administrator/Director of Care (Admin/DOC); RAI Coordinator; Programs Manager; Physiotherapist; Registered Nurse (RN); Registered Practical Nurse (RPN); and Personal Support Workers (PSW). During the course of the inspection, the inspector(s) observed staff to resident interactions; reviewed clinical records; reviewed licensee policies related to Head Injury Routine; and Falls Prevention and Management. The following Inspection Protocols were used during this inspection: Falls Prevention Findings of Non-Compliance were found during this inspection. Page 2 of/de 6

3 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 Non-compliance with requirements under (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.) The following constitutes written notification of non-compliance under paragraph 1 of section 152 of the LTCHA. WN Avis écrit VPC Plan de redressement volontaire DR Aiguillage au directeur CO Ordre de conformité WAO Ordres : travaux et activités 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. Ce qui suit constitue un avis écrit de nonrespect aux termes du paragraphe 1 de l article 152 de la LFSLD. WN #1: The Licensee has failed to comply with O.Reg 79/10, s. 8. Policies, etc., to be followed, and records Specifically failed to comply with the following: s. 8. (1) Where the Act or this Regulation requires the licensee of a long-term care home to have, institute or otherwise put in place any plan, policy, protocol, procedure, strategy or system, the licensee is required to ensure that the plan, policy, protocol, procedure, strategy or system, (a) is in compliance with and is implemented in accordance with applicable requirements under the Act; and O. Reg. 79/10, s. 8 (1). (b) is complied with. O. Reg. 79/10, s. 8 (1). Findings/Faits saillants : 1. Related to Log #O : Page 3 of/de 6

4 The licensee has failed to ensure that the policies related to Head Injury Routine, and Falls Prevention and Management are complied with. O. Reg. 79/10, 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. 49(1) The falls prevention and management program must, at a minimum, provide for strategies to reduce or mitigate falls, including the monitoring of residents, the review of resident's drug regimes, the implementation of restorative care approaches and the use of equipment, supplies, devices and assistive aids. - (2) Every licensee of a long-term care home shall ensure that when a resident has fallen, the resident is assessed and that where the condition or circumstances of the resident require, a post-fall assessment is conducted using a clinically appropriate assessment instrument that is specifically designed for falls. Review of Licensee Policy entitled "Fall Prevention and Management" VI-G dated May 2012 indicates: - the Registered staff will "...the physician should be contacted and/or arrange for immediate transfer to the hospital, the POA/Substitute Decision Maker will be notified." - "Initiate a head injury routine if a head injury is suspected or if the resident fall is unwitnessed." - "If a fall occurs then all staff will:...proceed with the head to toe and head injury assessment. The initial post-fall assessment note must include the following physical assessment for injuries..." - the Registered staff will "...Complete Falls Incident Report, under the Risk Management portal in the computerized record, an associated progress note will be generated;" Review of Licensee Policy entitled "Head Injury" VII-G dated November 2013 indicates: - "all unwitnessed resident falls will be assessed for a potential head injury." - "Notify Physician of resident's condition and vitals." - "Notify the resident's Power of Attorney for Personal Care of incident and condition of resident.." Page 4 of/de 6

5 - "Document assessments and all interventions taken on the progress notes and the vital sign recordings o VII-G-10.22(a) Head Injury Routine Monitoring Record and place in the resident's chart upon completion." Resident #1 was found sitting on the floor in the resident's bedroom. Review of clinical records indicated that Resident #1 was assessed by a registered staff member and no injuries were noted. The resident was placed in bed, call bell within reach and bed at lowest level with bed alarm on. The resident's Substitute Decision Maker (SDM) was notified however there is no evidence of the physician being notified. There is no evidence of a Head Injury Routine being completed for this unwitnessed fall. On a subsequent date Resident #1 was found sitting on the floor in front of the nurses station by a member of the registered staff. Another resident reported to staff that Resident #1 had sustained a possible head injury. Review of clinical records indicated that a Head Injury Routine was completed as per the scheduled routine. There is no evidence of the resident's SDM or Physician being notified, or a post-fall assessment being completed using a clinically appropriate tool designed for falls. Subsequently Resident #1 was heard falling by a member of staff and found sitting on the floor in the hallway. Review of clinical records indicates that Resident #1 did not sustain any injuries or appear to hit her head. Review of clinical records indicates a Head Injury Routine was initiated however there is no evidence of assessment data as per the scheduled routine for this unwitnessed fall. There is no evidence that Resident's #1's SDM or Physician was notified. On a subsequent date Resident #1 fell in front of the nursing station. Review of clinical records indicates that Resident #1 did not sustain any injuries. Resident #1's SDM was notified however there is no evidence of notification of the Physician. Interview conducted with Staff #100 who reported that if a resident fell witnessed or un-witnessed, staff take vital signs, assess for injury, treat for injury if required, contact EMS if needed for transfer to hospital, call or fax the Physician, notify the Resident's SDM, complete a post fall assessment note and risk management, and if the fall is unwitnessed staff also start a Head Injury Routine. Interview conducted with Admin/DOC who reported the expectation regarding falls is for staff to assess the resident, notify SDM and Physician (which can be done by fax, note in MD s book or telephone depending on severity of injury/fall); transfer the Page 5 of/de 6

6 resident to hospital if required, and document the fall in the Incident report and Post Fall Assessment Note. If the fall is unwitnessed a Head Injury Routine is started with the frequency as per chart on the top of form. The Admin/DOC reviewed Resident #1's Falls Incident Reports and related progress note documentation, and confirmed lack of following proper procedure related to falls. The Admin/DOC reported all registered staff have received education on Risk Management and documentation and the Admin/DOC is reviewing all incident reports closely for proper documentation. [s. 8. (1) (a),s. 8. (1) (b)] Additional Required Actions: VPC - pursuant to, 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 the licensee policies related to Head Injury Routine, and Falls Prevention and Management are in compliance with and implemented in accordance with all applicable requirements under the Act; and complied with, to be implemented voluntarily. Issued on this 10th day of October, 2014 Signature of Inspector(s)/Signature de l inspecteur ou des inspecteurs Page 6 of/de 6