OAdministrationMOHLTC CORRECTIVE ACTION PLANSPlan of Corrective

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OAdministrationMOHLTC CORRECTIVE ACTION PLANSPlan of Corrective Powered By Docstoc
					Ministry of Health                    Ministry of Health                     Ministère de la Santé                                                      Plan of Corrective Action
                                      and Long-Term Care                     et des Soins de longue durée                                                                            DIETARY


                                      Community Health Division              Division de la santé communautaire
                                      Central South Region                   Bureau régional du Centre-Sud
                                      119 King Street West, 11th Floor       119, rue King ouest, 11e étage
                                      Hamilton ON L8P 4Y7                    Hamilton ON L8P 4Y7
                                      Telephone: (905) 546-8294              Telephone: (905) 546-8294                                            Plan des mesures correctives
                                      Facsimile: (905) 546-8255              Télécopieur: (905) 546-8255

Name of Long-Term Care Facility/Nom de l’établissement de soins de longue durée   Date of review/inspection/ Date de l’inspection              Ministry Representative/Représentate(e) eu
                                                                                  From/de   August 13, 2007               To/à August 16/07    ministère
Classis Hamilton Homes for the Aged o/a SHALOM MANOR,                                                                                          Tammy Szymanowski, Compliance Advisor
Grimsby
                                                                                  Type of review/inspection/Type                    Plan submitted by/Plan   Plan receipt date/Date de
                                                                                  d’inspection                                      soumis par               réception du plan
                                                                                  ANNUAL                                            CHRISTOPHER   RYNBERK,   August 31,2007
                                                                                                                                    CEO
Standards/Criteria   Ministry review/inspection results                                         LTC Facility plan of corrective action
 Normes/Critères
                     Résultats de l’inspection du ministère                                     Plan des mesures correctives de l’établissement de SLD
    Act/Reg
    Loi/Règl.

                     The following previously identified unmet criteria have been
                     re-issued:                                                                 1. The CELIAC Diet will be added to the therapeutic spreadsheets
                                                                                                2. The dietary staff will be in-services in September on therapeutic diets, including the
   P1.3              There shall be an established menu cycle for both                          CELIAC Diet
 Re-issued           regular and therapeutic diets, including texture
 June 2006           modifications and snacks.

                     This criterion was not met as evidenced by:
                     The lack of a menu cycle for a therapeutic diet. For
                     example, there is no established menu cycle for a resident
                     on a Celiac diet as outlined in the homes policy.                          Responsibility: > Dietary Services Manager/Registered Dietitian
                                                                                                Planned Date of Corrective Action: > September 30, 2007
  B3.23     Each resident shall receive nutritional care according to
Re-issued   his/her assessed needs and measures shall be taken to           1. Dietary staff to be in-serviced in September on therapeutic diets and the importance of
            identify and address problems related to nutrition.             following directions on the serving notes.
June 2006
            This criterion was not met as evidence by:                      2. Nursing staff to be in-serviced on referring to the resident list to ensure that they
            Resident did not always receive the correct diet as indicated   receive the correct diet.
            on the servery list, for example three residents on a minced    3. Guidelines for thickening fluids will be available to nursing staff to ensure that
            and/or minced meat texture received puree texture, a            residents receive thickened fluids according to their diet order.
            resident on puree texture received minced texture; and          4. Nursing staff to be in-serviced regarding thickened fluids and giving special
            several residents on chopped texture received regular           nourishments to residents as per their care plan.
            texture.                                                        5. Monitored by Registered staff daily
            Residents on thickened fluids did not always receive the        6. Audits to be completed weekly by DOC
            appropriate consistency (honey, nectar, pudding) as
            ordered. Guidelines outlining amounts of thickener to be
            used for differing consistencies (nectar, honey, pudding)
            need to be available and reviewed with staff to ensure
            standardization.
            Residents requiring special nourishments did not always
            receive the nourishments as indicated on their plans of care.
            For example, five residents were to receive pudding,
            however, it was not offered; and one resident was to receive
            arrowroot cookies however, this was not available/provided.     Responsibility: > Dietary Services Manager, DOC, Registered staff
                                                                            Planned Date of Corrective Action: > September 30, 2007
 P1.25      Delivery of a meal to residents requiring assistance in         1.Nursing staff to be in-serviced on the requirement that residents’ meals not be
Re-issued   eating shall occur no more than five minutes in advance         delivered more than 5 minutes prior to providing assistance to the resident to eat the
            of assistance being provided.                                   meal.
  2003                                                                      2.Monitored by Registered staff daily
  2004      This criterion was not met as evidenced by:                     3.Audits to be completed weekly be DOC, CEO monthly
            Delivery of a resident’s meal sat thirty minutes (resident’s
            room) prior to assistance being provided.                       Responsibility: >DOC
                                                                            Planned Date of Corrective Action: September 30, 2007
  B3.25     The Food and fluid intake of each resident who is               1.The procedure for passing nourishments has been revised to ensure that the
Re-Issued   identified at nutritional risk shall be monitored and steps     documentation is accurate and matches the residents’ consumption.
            shall be taken to address the problem.                          2.Staff to be in-serviced on this new procedure.
June 2006                                                                   3.Monitored by Registered staff daily
            This criterion was not met as evidenced by:                     4.Audits to be completed by DOC weekly, CEO monthly
            Food and fluid documentation was completed, however,
            documentation was not always accurate, for example
            resident’s food and fluid records indicated nourishment was
            taken, however, residents did not receive their nourishments
            during the course of the review.
                                                                            Responsibility: Registered staff, DOC
                                                                            Planned Date of Corrective Action: September 30, 2007
        The following unmet criteria have been issued:                   1. The process for serving snacks hs been revised to ensure that all residents will be
                                                                         offered snacks by staff between meals and in the evenings.
        Snacks shall be offered to all residents at mid-afternoon        2. Nursing staff to be in-serviced on this new procedure.
P1.18   and at bedtime, unless contraindicated in individual             3. Monitored daily be Registered staff.
(new)   residents’ plan of care.                                         4. Audited weekly be DOC, monthly by CEO

        This criterion was not met as evidenced by:
        During the course of the review not all residents were           Responsibility: Registered staff, DOC CEO
        offered snacks and PM snack (examples discussed).                Planned Date of Corrective Action: September 30, 2007
P1.17   Beverages shall be offered to all residents at meals,            1. The process for serving beverages at mealtimes, between meals and at bedtime has
(new)   between meals and at bedtime, unless contraindicated             been revised to ensure that all residents are offered beverages.
        in individual residents’ plans of care.                          2. Nursing staff to be in-serviced on this standard.
                                                                         3. Monitored daily be Registered staff
        This criterion was not met as evidenced by:                      4. Audited weekly by DOC, monthly by CEO
        Beverages were not always offered between meals in all           Responsibility: Registered staff, DOC, CEO
        home areas throughout the review.                                Planned Date of Corrective Action: September 30, 2007
P1.27   Dietary services shall be organized to provide nutritional       1. Diet lists have been attached to nourishment carts for availability of staff reference to
(new)   care according to residents’ needs, consistent with their        residents diets.
        plans of care.                                                   2. Nursing staff to be in-serviced on the importance of having correct diet orders on the
                                                                         Med Reviews, that diet orders indicate both diet, texture, fluid consistency, and that diet
        This criterion was not met as evidenced by:                      orders are consistent with care plans.
        Nourishment lists were not provided with the nourishment         3. Audited weekly by DOC, monthly by CEO
        carts and staff did not reference lists during the passing of
        snacks/beverages. Diet orders were not always carried
        through on the med reviews resulting in incorrect diet orders.
        Diet orders did not always indicate diet and texture of diet
        and not all residents had a current diet ordered. It was also
        noted that not all diets listed on the care plans were           Responsibility: Registered staff, DOC, CEO
        consistent with the diet orders.                                 Planned Date of Corrective Action: September 30, 2007
B3.24   Each resident’s height shall be recorded on admission            1. All residents with weight loss/gain will be evaluated and referral sent to the registered
(new)   and his/her weight shall be measured and recorded on             dietitian for documention, and action taken as required.
        admission and subsequently at least monthly. Changes             2. Nursing staff to be in-serviced on this standard
        in weight shall be evaluated and action shall be taken as        3. Audited weekly by DOC, monthly by CEO
        required.

        This criteria was not met as evidenced by:
        Changes in weight were not always found to be evaluated
        and action taken in a timely manner. For example, six of
        seven residents reviewed for weight loss/gain did not have
        an evaluation and documented referrals for the Dietitian and
        there was not action taken as required. It was also noted        Responsibility: Registered staff, DOC, CEO
        that re-weights were not always taken and recorded as            Planned Date of Corrective Action: September 30, 2007
        appropriate.

				
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