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1 the Homes Division Inspections Branch Division des foyers de soins de longue durée Inspection de Ottawa Service Area Office 347 Preston St Suite 420 OTTAWA ON K1S 3J4 Telephone: (613) Facsimile: (613) Bureau régional de services d Ottawa 347 rue Preston bureau 420 OTTAWA ON K1S 3J4 Téléphone: (613) Télécopieur: (613) Public Copy/Copie du public Report Date(s) / Date(s) du apport Aug 30, 2016 Inspection No / No de l inspection 2016_219211_0016 Log # / Registre no Type of Inspection / Genre d inspection Complaint Licensee/Titulaire de permis CVH (No.6) GP Inc. as general partner of CVH (No.6) LP c/o Southbridge Care Homes Inc. 766 Hespeler Road, Suite 301 CAMBRIDGE ON N3H 5L8 Home/Foyer de Parisien Manor 439 SECOND STREET EAST CORNWALL ON K6H 1Z2 Name of Inspector(s)/Nom de l inspecteur ou des inspecteurs JOELLE TAILLEFER (211) Inspection Summary/Résumé de l inspection Page 1 of/de 11

2 the The purpose of this inspection was to conduct a Complaint inspection. This inspection was conducted on the following date(s): August 9, 10, 11, 12, 15, The inspection is related to the complaint about the continence care and the resident's unexpected death. During the course of the inspection, the inspector(s) spoke with the Senior Administrator, Administrator/DOC, Physician, Registered Nurses (RN), Registered Practical Nurses (RPN), Personal Care Workers (PSW), and family member. The inspector also reviewed resident health records, reviewed staff schedules, and reviewed several of the home's policies and procedures. The following Inspection Protocols were used during this inspection: Continence Care and Bowel Management Hospitalization and Change in Condition Infection Prevention and Control During the course of this inspection, Non-Compliances were issued. 2 WN(s) 2 VPC(s) 0 CO(s) 0 DR(s) 0 WAO(s) Page 2 of/de 11

3 the 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 (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 of non-compliance under paragraph 1 of section 152 of the LTCHA. 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 Reports re critical incidents Specifically failed to comply with the following: s (1) Every licensee of a long-term care home shall ensure that the Director is immediately informed, in as much detail as is possible in the circumstances, of each of the following incidents in the home, followed by the report required under subsection (4): 2. An unexpected or sudden death, including a death resulting from an accident or suicide. O. Reg. 79/10, s. 107 (1). Page 3 of/de 11

4 the Findings/Faits saillants : 1. The licensee has failed to ensure that the Director is immediately informed, in as much details as is possible in the circumstances of an unexpected or sudden death. The progress notes and interview with the DOC revealed the resident passed away on an identified day and was pronounced dead at a specified time. Interview with RN #100 revealed the resident was not officially a palliative resident. Interview with the DOC revealed the resident s Advanced Healthcare Directive was to transfer the resident to the Acute Care Hospital with CPR. Interview with the DOC revealed, the resident s death was sudden but it was not unexpected. The physician and the coroner were contacted by the nurse. The DOC confirmed that the Director was not informed immediately of the sudden death of resident #001. [s (1) 2.] Additional Required Actions: VPC - pursuant to the, 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 Director is immediately informed, in as much details as is possible in the circumstances of an unexpected or sudden death, to be implemented voluntarily. WN #2: The Licensee has failed to comply with LTCHA, 2007, s. 6. Plan of care Page 4 of/de 11

5 the Specifically failed to comply with the following: s. 6. (1) Every licensee of a long-term care home shall ensure that there is a written plan of care for each resident that sets out, (a) the planned care for the resident; 2007, c. 8, s. 6 (1). (b) the goals the care is intended to achieve; and 2007, c. 8, s. 6 (1). (c) clear directions to staff and others who provide direct care to the resident. 2007, c. 8, s. 6 (1). s. 6. (9) The licensee shall ensure that the following are documented: 1. The provision of the care set out in the plan of care. 2007, c. 8, s. 6 (9). 2. The outcomes of the care set out in the plan of care. 2007, c. 8, s. 6 (9). 3. The effectiveness of the plan of care. 2007, c. 8, s. 6 (9). s. 6. (10) The licensee shall ensure that the resident is reassessed and the plan of care reviewed and revised at least every six months and at any other time when, (a) a goal in the plan is met; 2007, c. 8, s. 6 (10). (b) the resident's care needs change or care set out in the plan is no longer necessary; or 2007, c. 8, s. 6 (10). (c) care set out in the plan has not been effective. 2007, c. 8, s. 6 (10). Findings/Faits saillants : 1. The licensee has failed to ensure that there is a written plan of care for each resident that sets out clear directions to staff and others who provide direct care to the resident. The following finding is related to a family s concern that resident #001's death was unexpected and that the cause of death was unknown. (Log # ) Interview with the family member revealed that the death of resident #001 was suspicious since the death certificate indicated that resident died suddenly and that the resident's cause of death was unknown. Resident #001 was admitted on an identified day with cognitive impairment and multiple medical diagnosis. The resident passed-away two months later. Review of the form titled New Admit/Re-Admit Med Rec: MAR and Drug Record Book Sheet dated on the resident's admission indicated the following: Page 5 of/de 11

6 the -DNR-level Three, -Transfer to the hospital, and -No Cardiopulmonary resuscitation (CPR). Review of the Advanced Healthcare Directives form and interview with the Administrator/DOC revealed that the resident or their substitute decision maker (SDM) can decide between four directive levels specified on the form as followed: 1-Comfort measure only (palliative care) Comfort Care, oral fluids Pain management, medications only No diagnostic tests No transfer to hospital No CPR 2-Comfort measures with additional treatment available in the home in addition to above Oral antibiotics Laboratory testing 3-Transfer to Acute Care Hospital without CPR Hospital emergency department will assess No CPR performed 4-Transfer to Acute Care Hospital with CPR Transfer to hospital CPR initiated in the case of witnessed arrest. The above form needs to be signed by the resident or the Substitute Decision Maker (SDM). The progress notes dated on an identified date, indicated the SDM was called as there was no medical directive signed. The SDM was reminded to come to the home to decide which advance Directive level he/she wanted for the resident. The progress notes indicate that the resident will be treated as a full code. The following day, the progress notes indicated the Advanced Health Medical Directives form was re-signed by the substitute decision maker (SDM) to have the resident at level four and to initiate the CPR in the case of a witnessed arrest. Page 6 of/de 11

7 the The Advanced Healthcare Directives form signed by the SDM on the day of the resident's admission showed that the No CPR was crossed out with a line and altered to wants CPR and initialed sixteen days later by an identified registered nurse. Another Advanced Healthcare Directives form dated sixteen days after the resident's admission indicated that the resident s SDM signed the sheet directing the staff to transfer the resident to Acute Care Hospital with CPR and to initiate the CPR in the case of witnessed arrest. Twenty-four days after the resident's admission, the progress notes indicated the resident is a full code. One month later, the progress notes reiterated that the resident was advance directive #4. The progress notes written by an identified RPN on the day the resident passed-away indicated that he/she was called by a PSW at a specified time in the identified area. The resident was brought from the identified area to another location and the RN was called. No pulse could be palpated. The progress notes written on the day the resident passed-away and interview with RN #103 indicated that when he/she was called around a specific time, the resident was found sitting in his/her wheelchair at an identified location with an identified RPN. The resident was pronounced dead at a specific time. The physician and the coroner were informed. RN #103 revealed the CPR was not initiated for resident #001. Interview with PSW #106 on August 10, 2016, revealed he/she saw resident #001 becoming unresponsive while sitting in the identified area on the day the resident passed-away. He/she screamed for help. A nurse wheeled the resident outside of the specified area. Interview with PSW #105 on August 10, 2015, revealed he/she saw the nurse trying to take the resident s oxygen saturation on the day the resident passed-away. PSW #106 and #105 were not aware of the resident s Advanced Health Care Directive level. Interview with RPN #115 revealed when he/she wheeled the resident from the specified area to another location. The vital signs were taken and the resident did not have a pulse. The RN was called. The RPN stated that she believed the resident to be a Do not Page 7 of/de 11

8 the Resuscitate (DNR). The sheet inside of the resident s front chart indicated the resident was a DNR. Interview with the DOC on August 10, 2016, revealed that the Do not Resuscitate Confirmation form dated on the day the resident was admitted was possibly still placed in the resident s front chart and was not replaced with the new updated Advanced Healthcare Directives completed and signed by the SDM sixteen days later after the resident's admission. He was also of the impression that the resident was a DNR. The DOC confirmed that the staff did not have clear direction related to the resident s Advanced Healthcare Directives in the resident s written plan of care. [s. 6. (1) (c)] 2. The licensee failed to ensure the provision of the care set out in the plan of care is documented. The following finding is related to a family s concern that resident #001's assessment and the interventions for the continence care were not properly given. (Log # ) Review of the Treatment Administration Record (TAR) for a identified month indicated that the specified continence care intervention should be done weekly and as needed on the first specific day of the week. Review of the Extendicare s policy # RESI titled Resident Care Manual Activities of Daily Living subject: Care of Resident with this specific continence care, dated February 2006, indicated the registered staff needs to perform the continence care intervention at least weekly and according to the Care Plan. Interview with RN #100 on August 10, 2016, revealed that the registered nurses has the responsibility to make sure the continence care equipment has been changed weekly by the PSWs. The PSWs will document on the PSW s treatment administration record (TAR) when the continence care intervention was performed. Interview with the DOC on August 11, 2016, revealed the resident s written plan of care did not indicate that Resident #001 had the specific continence care. Interview with the RN #100 on August 10, 2016 and the DOC on August 11, 2016, confirmed that the staff did not document on the TAR that the resident s provision set out in the plan of care relating to the continence care intervention was performed for a specify week. [s. 6. (9) 1.] Page 8 of/de 11

9 the 3. The following finding is related to a family s concern that resident #001 s continence care intervention was not properly provided after he/she returned from the medical leave on a specified month and he/she developed an infection. (Log # ) Resident #001 s current written plan and interview with the DOC on August 11, 2016, revealed the resident s written plan of care did not indicate that resident #001 had the specify continence care equipment. Resident #001 s Flow sheets for three months indicated the resident had the specify continence care for two months. The resident left for medical leave for three days. The resident s continence care intervention was stopped when he/she returned from the medical leave. Nine days later, the specified continence care was re-started. Review of the Extendicare s policy # RESI titled Resident Care Manual Activities of Daily Living subject: Care of Resident with the specific continence care, dated February 2006, indicated the staff needs to record and report the output such as the amount and colour of the urine on each shift. Interviews with RN #100 on August 10, 2016 and the DOC on August 11, 2016, revealed that the resident had the specific continence care when he/she returned from the medical leave, which was stopped on that day. The specified continence care intervention was restarted on an identified date due to resident s specific health issue. RN #100 on August 10, 2016, revealed that the role of the nurse is to ensure the resident has adequate output. The progress notes on an identified date, indicated the resident passed-away at an identified time and the Flow sheet on that day does not indicate the amount of output for the specified continence care intervention before his/her death. Interview with the PSW #105 on August 10, 2016 and the DOC on August 11, 2016, confirmed that the output for the continence care was not documented for 21 shifts in a period of two months. [s. 6. (9) 1.] 4. The licensee has failed to ensure that the resident is reassessed and the plan of care reviewed and revised at least every six months and at any time when the resident s care needs. Page 9 of/de 11

10 the Review of resident #001 s admission written plan of care dated on an identified date indicated that the resident has urinary issue. The interventions indicated that the staff will provide support by bringing the resident to the washroom after each meal to increase resident level of continence. The resident s progress notes indicated the resident left for a medical leave for seven days on the month he/she was admitted in the home. Interview with RN #100 revealed the resident returned from the medical leave with a specific continence care. The resident s Flow sheets for a specified month indicated that the staff started to calculate the amount of outputs from the specify continence care on the day he/she returned from the medical leave during the identified shift. The progress notes and interview with the DOC indicated that the resident s continence care intervention was stopped one month later in the home as prescribed in the Physician s epen Order. The progress notes and interview with RN #100 indicated the continence care intervention was re-started nine days later as prescribed in the Physician s epen Order. Interview with the DOC confirmed that the resident s current written plan of care and the Kardex was not updated when the resident s continence care was changed. [s. 6. (10) (b)] Additional Required Actions: VPC - pursuant to the, 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 there is a written plan of care for each resident that sets out clear directions to staff and others who provide direct care to the resident, the provision of the care set out in the plan of care is documented and that the resident is reassessed and the plan of care reviewed and revised at least every six months and at any time when the resident s care needs, to be implemented voluntarily. Page 10 of/de 11

11 the Issued on this 13th day of September, 2016 Signature of Inspector(s)/Signature de l inspecteur ou des inspecteurs Original report signed by the inspector. Page 11 of/de 11

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