Whaler's Cove

EOEA reviewed response times and tests of the emergency response system from the calendar years 2022 to 2024 to determine compliance with Service Coordination requirements.

In the month of December 2022 there were 26 e-call response times over the 10 minutes required by the Residence policy.

In the month of June 2023 there were 24 e-call response times over the 10 minutes required by the Residence policy.

In the month of August 2024 there were 20 e-call response times over the 10 minutes required by the Residence policy.

EOEA reviewed the records of nine Residents to determine compliance with requirements for Screening and Assessment, Service Plan Development and Service Plan Requirements.

Six records were missing documentation of the Resident’s risk for elopement on the initial assessment.

Seven records were missing documentation of assessment findings for history of behaviors which may present a risk to the health and safety of the Resident or others.

Two records were missing documentation of a Service Plan reassessment required within 30-days after the commencement of residency.

Two records were missing documentation of a reassessment and service plan review being completed every six months.

EOEA reviewed the Residence records of 12 Residents utilizing bed rails / U-bars or similar devices for the period of 2023 through the date of the Compliance Review to determine compliance with the required assessment by a physical/occupational therapist every six months.

Documentation of an assessment conducted by a physical/occupational therapist determining that the Resident can independently navigate around the bed rail / assistive device was missing for six Residents.

EOEA reviewed the Residence’s Emergency Plan to ensure compliance that the Residence can address potential disasters and emergencies.

Documentation to confirm a elopement drill and a fire drill conducted by the Residence on the third shift in the 2023 calendar year was missing.

EOEA reviewed documentation to ensure the Residence has established an effective, ongoing quality improvement and assurance program for Service Planning, Resident Safety Assurances and Medication Quality for the calendar years 2022, 2023 and 2024.

Documentation of the date of the review was missing in calendar years 2022 and 2023.

Resident Safety Assurances

Documentation of the date of the review was missing in calendar years 2022 and 2023.

EOEA observed two PCA staff providing medication assistance to 10 Residents to ensure the Residence has developed and implemented systems that support and promote safe SAMM:

One Resident’s family filled cassette was missing the name and room number of the Resident.

One Resident had one loose pill in their medication storage unit.

EOEA reviewed the Residence records and submitted incident reports from October 30, 2022 through October 17, 2024 for evidence that all occurrences of an incident or accident that has or may have a Significant Negative Effect on a Resident’s health, safety or welfare were reported to EOEA within 24 hours after the occurrence of the incident or accident.

The Residence filed 26 incident report greater than 24 hours after the occurrence of the incident during the period reviewed.

EOEA reviewed the Residence’s documentation for evidence of compliance with training needs assessment regulations.

Documentation to support that the Residence has conducted a training needs assessment in the 2022 and 2023 calendar years were missing.

EOEA reviewed the records of nine Residents to determine compliance with the requirements that a nurse review the Resident’s service plan with all relevant personal care workers within the 48 hours after the provision of service or with any change of condition for the Resident.

Five records were missing signature documentation to support that Introductory Visits have been conducted with all applicable staff prior to or within 48 hours after the provision of Personal Care services.

EOEA reviewed the records of four PCA personnel to verify a qualified nurse shall, at least once every six months, evaluate the Personal Care Services and his or her awareness of SAMM regulations and applicable policies and verifies his or her demonstrated ability to comply with SAMM regulations and related Residence policies and procedure provided by personal care staff of the Residence or by contracted providers.

Documentation of the nurse signature for PCA skills evaluations every six months of calendar years 2023 and 2024 were missing for three PCA records reviewed.

Documentation of the nurse signature for SAMM skills evaluations every six months of calendar years 2023 and 2024 were missing for three PCA records reviewed.

Corrective Actions.