CAF-JTFC 3350 OpLASER 20/01

3350-0p LASER 20-01 (COS)

1. The Honourable Doug Ford, Premier of Ontario
2. The Honourable Christine Elliott, Minister of Health and Long-Term Care
3. The Honourable Sylvia Jones, Solicitor General of Ontario
4. The Honourable Monte McNaughton, Minister of Labour, Training and Skills Development
5. The Honourable Todd Smith, Minister of Children, Community and Social Services
6. The Honourable Lisa MacLeod, Minister of Heritage, Sport, Tourism and Culture Industries
7. The Honourable Prabmeet Singh Sarkaria, Associate Minister of Small Business and Red Tape Reduction
8. The Honourable Merrilee Fullerton, Minister of Long-Term Care
9. Major General Dany Fortin, Vice Commander Canadian Joint Operations Command
10. Lieutenant-General Wayne Eyre, Commander Canadian Army
11. Brigadier-General Stephen Cadden, Commander Joint Task Force Central (JTFC)
12. Colonel Mark Misener , Deputy Commander JTFC
13. Colonel David Anderson , Chief of Staff JTFC
14. Colonel John McQuillan , Chief Operations Officer JTFC
15. Colonel Chris McKenna , Chief Logistics Officer JTFC
16. Colonel Paul Bury , Chief Personnel Officer JTFC
17. All Regional Commanders within the JTFC Area Of Responsibility (AOR)

The best way to prevent the spread of COVID-19 is to practice social distancing, wear a face covering when in public, wash your hands often with soap and water for at least 20 seconds, avoid touching your face, cover coughs and sneezes, clean and disinfect frequently touched surfaces, and stay home if you are feeling sick.

1. Sir, as auth al Ref A and directed at Ref B, JTFC has employed Augmented Civilian Caree (ACC) teams, since 28 Apr 20, in five Province of Ontario-prioritized Long Tenn Care Facilitiese(LTCF) that were in urgent and immediate need of personnel to provide humanitarian relief andemedical support.
2. Since arrival, and with the benefit of two weeks of observation, CAF ACC have identified a number of medical professional and technical issues present at the five LTCF. Fromea command and medical perspective, challenges were expected at these facilities given the severe deficiencies and shortfalls that existed/exist at the provincially-prioritized assignments; the CAFewas meant to go to locations with the greatest need of our support. This is a reflection of theeconditions at those distressed locatious. Consequently, issues and challenges have been collatedeand consolidated in medical reporting in the key areas of Standards and Quality of l,fedical Care.
   Annexes A-B provide detail by individual LTCF. The pwpose of this letter is to ensure that theseeobservations do not go unnoticed by our chain of command. the Province of Ontario, and mosteimportantly at the individual LTCf where efforts are currently underway in an open, tmnsparenteand collaborative manner at the local level between each LTCF and ACC to aid in recovery byeaddressing the specific areas of observation.
3. Nothing in this letter is meant to encroach upon the purview of the CAF Surgeon General, the established relationship between that office and the Chief Medical Officer of Health for Ontario, or the formal and informal connections by the CFHS and its offices, with those medical and professional Colleges and Associations that represent the medical professionals and health care capabilities within the Ontario health care system. Rather, this is meant to compliment that discussion by ensuring a command awareness on these issues so as to support the Surgeon General, the CFHS and our CAF medical and non-medical general duly personnel as they execute daily tasks as an ACC team in this unexpected and difficult operating environment.
4. The Province of Ontario, and its Incident Mai1agemenl System (IMS) responsible to the Command Table and is responsible for dealing with the COVID crisis, co-chaired by the Provincial Deputy Ministers (DM) for both Health and for Long-Term Care, respectively, are aware that CAF ACC teams have made observations with Standards and Quality of Medical Care.Â
   Informally, key figures in the IMS understand the general themes of our observations but have not been privileged with specifics or detail. We have sought to make observations that are strictly factual in nature and are not meant to assess or pass judgement on LTCF leadership or staffs.
   From the perspective of our medical and non-medical personnel in-situ, however, the  observations are sufficiently serious in nature to warrant them also being shared with the Province of Ontario, given that the CAF is responding to their RFA and LTCF fall under the Province’s authority. I believe that this is best done under the Surgeon General’s purview, and JTFC can enable that via our Regional Surgeon who has established links with the Provincial IMS Lead and Operations Head. Additionally, I will make myself available, should it be directed. or desired, to address these issues at my level, with my Provincial counterparts: DM for Health, DM for Long.Term Care, or with the Deputy Solicitor General for Ontario (Dep SOLGEN) who is responsible for RFA within the Province.Â
5. Far more importantly for the health of the residents who are the focus of all concerned, is our transparency and collaborative work with each LTCF to improve the situation so as to have an immediate effect on both daily operations and incremental facility recovery. To that end, I can assure that each ACC team bas addressed their own observations with the L TCF management and the competent medical authority available at each site. Every engagement to date has been positive with an acknowledgement by the LTCF that they need to improve, with the improvement on these observed issues being as equal in importance to: overall recovery as proper staffwg, sufficiÂ¥ent medical resources and supplies, coherent management return on site and establish a working connection to respective health networks.Â
6. I believe care and attention by our ACC personnel remains our strongest tool in this domain. Notwithstanding the observed deviations in care and accepted practices, our CAF medical professionals lead by example in these LTCF and are ably supported by their non-medical general duty personnel and the structure of the Task Force that enables each ACC team. The content of the annexes was the result of the ACC Nursing Officer team leads, the work of the ACC Senior Nursing Officer, Capt K. Martin and the Regional Surgeon, LCol C. Mercer. Any specific interest with tbe Annex content is best directed via the Regional Surgeon as JTFC technical authority for the medical content.Â
7. Sir, I remain available at your convenience for direction or discussion.Â

Distribution List:

1. Chief of Staff, United States Army
2. Deputy Chief of Staff, G-3/5/7, United States Army
3. Commanding General, United States Army Europe
4. Commanding General, United States Army Central Command
5. Commanding General, United States Army Pacific Command
6. Commander, United States Special Operations Command

Annexes

• Annex A-Observation Report on LTCF Eatonville Care Centre
• Annex B -Observation Report on LTCF Hawthorne Place Care Centre
• Annex C -Observation Report on IJTCF Orchard VillaÂ
• Annex D-Observation Report on LTCF Altamont
• Annex E-Observation Report on LTCF Holland Christian -Grace ManorÂ

Distribution ListÂ

• Action
  • CJOC//ComdÂ
• InformationÂ
  • HQ CA//Comd/COS Ops/CA Surg
  • CJOC//DGOps/Command Sutgeon/LEGAD
  • CF H Svcs//Surg GeneraVDSG/DHSO

The most effective way to reduce the amount of plastic waste is to reduce the amount of plastic that is used in the first place. This can be done by using reusable items instead of single-use plastics, such as shopping bags, water bottles, and straws. Additionally, people can choose to buy products with less packaging or opt for products made from sustainable materials like bamboo or glass. Finally, recycling and composting plastic waste can help reduce the amount of plastic that ends up in landfills.

A.1 Summary of Findings

The Eatonville Care Centre (ECC) is a long-term care facility located in Etobicoke, Ontario. The facility provides 24-hour nursing and personal care services to residents with complex medical needs. During the observation period, the following findings were noted:

• The facility was clean and well maintained.
• Staff were friendly and professional in their interactions with residents and visitors.
• Residents appeared to be well cared for and comfortable in their environment.
• There was an adequate supply of medical equipment and supplies available for use by staff.
• The facility had a variety of activities available for residents, including music therapy, art classes, exercise classes, and social outings.
• Staff provided timely responses to resident requests for assistance or services.
• Residents had access to nutritious meals that met their dietary needs.
• The facility had a comprehensive safety plan in place that addressed potential risks associated with falls, fire safety, infection control, and other hazards.

1. I. Infection control:Â
   1. a. Isolation: COVID-19 positive residents allowed to wander. This means anyone in the facility (staff, residents, and vi,sitors) is at risk of being exposed and passing it throughout the home; as the resident’s location is not predictable, full appropriate PPE is not possible;Â
   2. b, PPE practices-resident rooms: facility staff ae wder the impre.ssion that if the infection between 2 residents is the saine, there’s no need to change their gown; andÂ
   3. c. PPB practices -outside rooms: Â¥ facility staff often wear PPE outside of rooms and at the nurses station.Â
2. 2. Standards of practice/aualitv of care concerns:Â
   1. a. Reusing hypodermoclysis supplies even after sterility has been obviously compromised ( e.g. catheter pulled out and on the floor for an undetermined amount of tune);Â
   2. b. Poor palliative care standards -inadequate dosing intervals for some medications, some options limited based on level of staff administering medication ( ex: hydromorphone injection won’t be given if RN unavailable);Â
   3. c. There are no mouth or eye care orders -or supplies for pa!lil!tive residents;Â
   4. d. Poor Foley catheter care. CAF SNO (Senior Nursing Officer) reports poor adherence to orders, no co.osistent safety checks. Significant incidents of excessive sediment or abnormal discharge and bleeding with no follow on action; and 
   5. e. Generally very poor peri-catheterization care reported. Example: Retracting penis foreskin to clean isn’t happening on a widespread level. CAF have fou.nd nearly a dozen incidents of bleeding fungal infections.Â
3. 3. Supplies:Â
   1. a. General culture of featr to use supplies because they cost money (fluid bags, dressings, gowns, gloves ‘ etc);Â
   2. b. Key supplies are often under lock and ¥ key, not accessible by those who need them for work (e.g. wipes for PSWs); and
   3. c. Expired 1nedication. Much of the ward stock was months out of date (inference: residents have likely been getting expired medication for quite some tune). 
4. 4. Ambiguity on local practices:Â
   1. a. Extra soaker pad: residents who routinely soil their bed despite incontinence products are not pennitted to have an extra soaker pad or towel in bed to help protect sheets and blankets from soiling. (PSVs are afraid for their jobs on this Â¥ issue) rationa!iilStiOu used is that an extra pad is undignified;Â
   2. b. Cohorting residents. Ministry requirement cited as reason they still have negative residents rooming with positive residents; andÂ
   3. c. Unable to post information tbat would greatly increase patient safety and appropriate care. Example: an inconspicuous card above bed that stated code status, diet texture/fluid consistency, transfer status etc. ,vas deemed to be “undignified”. This presents a safety risk to residents who may get improper care and liability risk to the care providers.Â
5. 5. Communication:Â
   1. a. PSVs can be task focused and do not always report discovered abnonnalities to registered staff;Â
   2. b. Policies and facility-specific procedures aren’t communicated to staff(example, how to sign for a narcotics shipment, what to do in the event of a call bell failure);Â
   3. Information about residents is difficult to access and hard to communicate ( example: a neurologic exam after a fall is hard to interpret when it’s unclear what the resident’s baseline neurologic status is);Â
   4. Information on LTCF COVID status (residents and staff) is not available or updated; and
6. Management is unable to effectively enforce restrictions on use of CAF PPE. 6. Staffin.:Â
   1. a. New staff that have been brought to LTCF haven’t been trained or oriented;Â
   2. b. LTFC is severely understaffed during day due to resident COinorbidities and needs (need more PSWs, RPN and RNs);
   3. MDs not present and have to be accessed by phone (not always within reach);Â
   4. Morale and well-being of staff at risk. Many are overworked, seem bwncd out and have no time off (some have not seen their families for weeks);Â
   5. e. The staffing is such that it is impossible to provide care at a pace that is appropriate to each resident or allow them any kind of independence. (example: a resident states he would like to ambulate to the toilet, a PSWs says, “110 I just changed him.” Or people are often sedated with narcotics when they are likely just sad or depressed in a context where there isn’t the staffing to support the level of care and companionship they need;
   6. f. ACC staff report not having witnessed any psychosocial support for th.ese residents who have all of a sudden had their families taken away (Reported as “It’s heartbreaking to get a report about someone Vho is “agitated and difficult” and has been getting PRN narcotics or benzodiazepines to sedate them but when you talk to them they just say they’re “scared and feel alone like they’re in jail” -no agitation or sedationtrequired;andÂ
   7. g. Gross in-adherence to some recurring orders ( example: regular vital signs or patient tu1ning); in some cases PSW$ are reported to asking ACC team members not to do these since they “wake up the resident”.Â
7. 7. Inanpro.,rjate Behaviour:Â
   1. CAF member have witnessed aggressive behaviour which ACC staff assessed as abusive/inappropriate. Incidents have been reported to management on numerous occasions. Witness reports have been completed and LTC ha$ commenced investigation to the knowledge of ACC staff. Examples include aggressiveness when changing incontinence product, not stopping or slowing when resident complained of pain, pulling residents, aggressive transfers impacting resident ability to participate in care as able (roll self in bed), degrading or inappropriate comments directed at residents etc; Annex Â¥ A to Observation Report on LTCFÂ
   2. b. Reports of inaccurate charting or documentation being amended by agency staff following submission regarding patient’s pain levels, nutrition, eating status etc; andÂ
   3. C. ACC staff report inaccurate reporting regarding resident’s status to family (feeding, pain levels, general condition, etc).Â
8. 8. ACC en2aeement with facili_ty –á staff:Â
   1. a. Concero.s were initially raised by the on-site SNO to local leadership. On 4 May 20, a telecoof was conducted between CO TBG I, OC ACC, and leadership from Eatonville Care Centre, as well as corporate management. Major concerns were raised, in particular staodards of care issues, poor IP AC, poor charting, narcotic misuse, and wound care. Concerns were raised in a collegial manner and facility staff advised they will address the deficiencies. Â¥ Annex B to ObserVation Report on LTCF Hawthorne Place Care CentreÂ

1.0 Introduction

This Annex A to the Observation Report on LTCF Eatonville Care Centre provides additional information on the facility’s operations and services. The report was conducted by an independent team of experts from the Canadian Institute for Health Information (CIHI). The team visited the facility on May 14, 2020 and observed its operations and services.

2.0 Facility Overview

Eatonville Care Centre is a long-term care facility located in Etobicoke, Ontario. It is owned and operated by Revera Inc., a leading provider of seniors’ care services in Canada. The facility offers a range of services including 24-hour nursing care, personal support, recreational activities, meals, housekeeping, laundry services, and social programs. It also provides specialized care for those with Alzheimer’s disease or other forms of dementia.

3.0 Quality Assurance Program

The Eatonville Care Centre has implemented a comprehensive quality assurance program that includes regular monitoring of staff performance and patient outcomes. The program also includes regular audits to ensure compliance with provincial regulations and standards of practice. In addition, the facility has established an internal complaints process to ensure that any concerns raised by residents or their families are addressed promptly and effectively.

4.0 Staffing Levels

The Eatonville Care Centre employs a total of 120 staff members who provide 24-hour nursing care to its residents. This includes registered nurses (RNs), licensed practical nurses (LPNs), personal support workers (PSWs), recreation therapists, dietitians, housekeepers, laundry attendants, maintenance personnel, and administrative staff. All staff members receive ongoing training in order to maintain their professional competencies and meet provincial standards of practice for long-term care facilities.

5.0 Resident Services

The Eatonville Care Centre offers a wide range of services designed to meet the needs of its residents including: 24-hour nursing care; personal support; recreational activities; meals; housekeeping; laundry services; social programs; specialized care for those with Alzheimer’s disease or other forms of dementia; physiotherapy; occupational therapy; speech therapy; music therapy; art therapy; pet therapy; aromatherapy massage therapy; spiritual counselling; nutrition counselling; medication management; footcare clinics; health promotion seminars/workshops/classes/groups/outings/trips/events etc.; transportation services for medical appointments etc.; access to community resources such as homecare agencies etc.; family meetings/support groups etc.; end-of-life planning etc..

6.0 Conclusion

The Eatonville Care Centre is committed to providing quality care to its residents through its comprehensive quality assurance program and highly trained staff members who are dedicated to meeting the needs of each individual resident in accordance with provincial standards of practice for long-term care facilities in Ontario

1. 1. lnfectiOJ1 control:
   1. a. Numerous fans blowing in hallways (increased spread of COVID-19);Â
   2. b. Poor train.tog and adherence to 1P AC protocols noted;Â
   3. c. Significant deterioration of cleanliness standards throughout LTC;Â
   4. d. Adherence to IP AC BPG is severely impacted. All ACC and GD pers report n.ll!llerous incidents of PPE breakdown by LTC staff. Protocols in place have a near 100% contamination rate for equipment, patients and overall facility. Nurses/PSW s are often observed not changing PPB for several hours while moving betw(!etl n11merous paticmt rootn&, Equipment is seldom/ever observed to be disinfected but is used between +ve/-ve patients. Med cart, BP cuffs, thermometers etc. not disinfected between uses;Â
   5. e. Little to no disinfection had been conducted at the facilities prior to CAF operations. Significant gross fecal contamination was noted in numerous patient rooms;Â
   6. f. Insect infestation noted within LTC -ants and cockroaches plus unknown observed;Â
   7. g. Delayed changing soiled residents leading to skin breakdown; and N95s provided to staff witl.lout fit-test.Â
2. 2. Standards of Practicef()ualilv of Care C9_nc.ernt 
   1. a. Forceful and aggressive transfers, little/no regular turning of patients leading to increased number and complexity of pressure ulcers;Â
   2. b. Forceful feeding obl;erved by stiff causing audtl>le choking/aspiration, forceful hydration causing audible choking/aspiration;Â
   3. c. Patients observed crying for help with staff not responding for (30 min to over 2 hours);
   4. Narcotics are not considered a high alert medication therefore this -is no mandatory independent verification required within the LTC. High risk of dosingÂ
   5. e. Activities of Daily Living-staff report residents having not been bathed for several weeks (noted at commencement of task);Â
   6. f. DNR status not posted call8ing staff to race to EMR during code! to determine DNR status. CPR has been initiated in absence of ability to verify DNR staf11s (likely futile, and also putting staff at risk as CPR is aerosol generating);Â
   7. g. Feeding status not posted/readily available. Given the lack of permanent staff or oversight, patient meals are often mixed up, with incidents of inappropriate meals being fed to residents with swallowing difficulties (increases likelihood of choking or aspiration);Â
   9. i. Access to PCC ( electronic health record) inconsistent and numerous reports of a lack of charting/documentation by staff causing significant gaps in information;
   10. j. Reports by SNO of little to no documentation on resident’s status within EMR for up to 6 montbs. Unclear regarding reasons for lack of charting but resident’s status indicated a requirement for additional information and documentation;Â
   11. k. Regular weUness ch cb suboptimal or inconsistent with staff resll.ltiog in many hours betw.een wel á á á s, cbecb, day/á ,._ght shift;Â
   12. 0 repo1 , .d jncidcnt of pati nti s mrt,end -6 á. _ d bottle n. being cl1 angcd for so longá the, contents á d become fuul ,and ooa,gulated; date and CJ(,piration of contents not note o . á .. á ttle;Â
   13. m, SNO report.ed incident ,of pennanent catheter b . iug in situ J weeks h e.yond schedmed chage date. Catheter was. c:hang d by SNO but stated documentation and adheremce to timeb . es ;vas pro biematic;Â
   14. n. Topical prescription :mediiein . shared betw,een residentsá a.ndÂ
   15. o. Staff report signific.-t lack of appropriate wound care to advanced (stage 4Amsta_gcab1e) wounds du. to signific .. t skmtage of suppUes” lack of docum-f!;ntation.. ánon-st rile, teohnique1. :0 ápacking or impiop.r packing of V-ou:nds.
3. 3 .. Supplies
   1. a. áw 0110d . re supplies. insufficie or lock_ d away -mgh turnover of -tatr d lack or famil á arity áwith á á -led to poor practaees due to supply shortage;Â
   2. áb. á áo -ern,ih cart ava1!labfo for w:e w. -e event of a cardfoi. arres.Â
   3. Cm ,. Linen. shortage noted, Either more .-ens, need t,o be –cha_ , d or Jaundry staff _ :-. . red rot night shift. Shortage :d to :resá dents s eep á g ,on beds with no linen tea.din, to increased skin breakdown; andÂ
   4. d. Av,ailabi .ity o iPads aá dl time constraints led to SLgni±ica, t lack of doCUIIllenta áon within BMR. Significant. aps in informatio -ex-is á .pec1aUy WR T pr Â¥ sure ulcer progress,.. swellowin_g status or pati,em mental staru.s.Â
4. 4. Ambiguity on local practices:
   1. a. .Palliative care ,orders Tlotá charted/unknown ro agency staff thus often not obsenred;Â
   2. Resident ceusu., ,and docum.en . ,TIOtl o-utdat-ed:; andÂ
   3. c. … Resident as.signmlmt is not clear for PSWs leadlng to residents”á..; , beá .. á , á’
5. Communication:
   1. Poor communicatio between shifts…
   2. ., ainge led oÂ
6. 6. Staffing:
   1. a. No (oivil1an) R in _.he building o: her’thain sá .. ,o, dunng’week:ends. SNO and Execáu’tive Directur (afao, an RN only Rl{s on si e on .m.unerou oceaswo-ns du á . ¥á the week Significant resaltarnt. safety co-ncems regarding patient ratios (I RN for :’up t,o 200 pati.ts ).:Â
   2. b Litt] .’. ror no orientation forá new s J re8,Ulting in lo . adherence to protoc-ols or a ngruficmt . ll’ID”C!JCSS of policy,Â
   3. Conta á . fonna ion and o -á. all schedu e not provided to unit s _ aff,cr-eates siginficant ddays f oru refe-rr_ai _ncl direction during, e ._ ergieD,cies.; Nursing .and ‘ . shift schedule poorly mnnag;ed. Brea.áá time is oot planne. the floor unatt -nde.Â
   4. d , á taff disappear and leaveáÂ
   5. e. SNO reports that agency pulled back/rerouted RNs when they found out CAP members present resulting in regular degradation of patient ratios and instability of planning;Â
   6. f. No shift handover., witnessed since arriving on site;Â
   7. g. PSW often rushed and leave food on table but patients often cannot reach or cannot feed themselves (therefore they miss meals or do not receive meal for hours);Â
   8. h. Public inter-professional disputes amongst agency/permanent staff; and
   9. i. ACC personnel are heavily relied upon to train and mentor new staff;Â
7. 7. ACC eneauement with fa.cilitv staff:Â
   1. a. Concerns were initially addressed by the on-site SNO to local leadership, including charge nurses. On 4 May 20, a teleconf was conducted between CO TBG 1, OC ACC, and leadership from Hawthorne Place, as well as corporate management.. Major concerns were raised, in particular standards of care issues, poor IP AC, poor charting, and narcotics misuse. Concerns were raised in a collegial lll.al!Jier and facility staff advised they ,viii address the deficiencies, however, given lack of resources available, they may have difficulty in affecting a plan.Â

C. Recommendations

1. The facility should ensure that all staff are trained in the proper use of personal protective equipment (PPE) and infection control practices, including hand hygiene, to reduce the risk of transmission of infectious diseases.

2. The facility should ensure that all staff are aware of the importance of reporting any changes in residents’ health status or behaviour to their supervisor or designated person immediately.

3. The facility should ensure that all staff receive regular training on the proper handling and disposal of hazardous materials, such as sharps and medical waste, to reduce the risk of injury or contamination.

4. The facility should ensure that all staff are aware of the importance of following established policies and procedures for infection prevention and control, including those related to hand hygiene, environmental cleaning and disinfection, safe food handling, and contact precautions for residents with communicable diseases.

5. The facility should ensure that all staff receive regular training on how to recognize signs and symptoms of common infectious diseases in order to take appropriate action if necessary.

6. The facility should ensure that all staff are aware of the importance of adhering to established protocols for responding to outbreaks or suspected cases of communicable diseases in order to minimize spread within the facility and community.

1. 1. J.!!fection control: MIC-
   1. a. Lack of cleanliness noted:Â
      1. I) -Cockroaches and flies present; andÂ
      2. 2) Rotten food smell noted from the hallway outside a patient’s room. CAF member found multiple old food trays stacked inside a bedside table.Â
   2. b. Inappropriate PPE use ntoted through.out all staff mg lovels ( doctors included); and Poor IPAC/PPE practices (double/triple gowning and masking, surgical maskÂ

The CDC does not recommend wearing scarves under masks. Scarves can interfere with the fit of the mask and reduce its effectiveness. It is important to make sure that your mask fits snugly against your face without any gaps or openings.

The standards of practice and quality of care concerns for healthcare professionals include:

1. Adhering to professional codes of ethics and standards of practice.
2. Ensuring patient safety and providing quality care.
3. Maintaining accurate and complete medical records.
4. Following evidence-based guidelines for diagnosis, treatment, and prevention of disease.
5. Communicating effectively with patients, families, and other healthcare providers.
6. Respecting patient autonomy and confidentiality in all interactions with patients.
7. Participating in continuing education activities to stay up-to-date on best practices in the field.

b. Patients being left in soiled beds for extended periods of time;

c. Patients not being provided with adequate nutrition or hydration;

d. Patients not receiving timely medical care or medications; and

e. Staff not responding to patient calls for help in a timely manner.

c. Inadequate nutrition;

d. Inadequate oral hygiene;

e. Incorrect positioning of the patient; and

f. Lack of communication between healthcare providers and family members.

d. Inadequate nutrition/hydration; and

e. Failure to monitor for aspiration.

The code bJ11e is not a valid code. The correct code for choking during feeding while supine is bJ12e. This code should be used to indicate that staff were unable to dislodge food or revive the resident.

It is important to prioritize the respect and dignity of patients in all healthcare settings. Caregivers should be provided with adequate resources and support to prevent burnout, such as access to mental health services, flexible scheduling, and regular breaks. Additionally, healthcare organizations should provide training on patient-centered care that emphasizes the importance of respecting patient autonomy and dignity. Finally, healthcare providers should strive to create a culture of respect and empathy for patients by actively listening to their concerns and providing compassionate care.

1. Administering the wrong medication or dose
2. Administering a medication to the wrong patient
3. Administering a medication at the wrong time
4. Failing to monitor a patient’s response to a medication
5. Failing to document a medication administration
6. Administering medications without proper authorization or prescription
7. Mixing up two medications with similar names or appearances
8. Not checking for drug interactions before administering multiple medications
9. Not verifying that the correct route of administration is being used
10. Not verifying that the correct form of the medication is being administered

‘

Residents should be provided with access to their food and important belongings. Staff should ensure that these items are within reach of the residents, and not placed out of their reach.

Nursing documentation should always accurately reflect the care that was provided to a resident. If nurses are found to be documenting assessments without actually having assessed the resident, they should be counseled and/or disciplined as appropriate. It is important for nurses to ensure that their documentation is accurate and reflects the care that was provided.

The staff should be commended for their quick response to the situation. They identified the potential fracture, and took appropriate action to ensure that the resident received the necessary medical care. The Med Tech and SNO should also be praised for their efforts in transferring the resident to the hospital in a timely manner.

j. Multiple falls, without required assessments following the fall, is a violation of the resident’s rights and should be reported to the appropriate authorities. The facility should also take steps to ensure that all falls are properly assessed and documented in order to prevent future falls and potential injury.

Inconsistent and suboptimal assessment and treatment of pain is a major issue in healthcare. Pain is often under-recognized, under-treated, or treated inappropriately. This can lead to unnecessary suffering for patients, as well as increased costs for the healthcare system. To address this issue, healthcare providers should ensure that they are properly assessing and treating pain in their patients. This includes taking a thorough history and physical exam, ordering appropriate tests and imaging studies, prescribing evidence-based treatments, monitoring patient response to treatment, and providing education about pain management. Additionally, healthcare organizations should develop policies and procedures to ensure that all patients receive consistent and effective pain management.

A. The lack of knowledge regarding what qualifies as a restraint is concerning. Restraints are any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. This includes but is not limited to bed rails, lap trays, mitts, vests and straps. Walking aids such as canes and walkers should not be removed unless they pose an immediate risk of harm to the patient or others in the facility. Mattresses should not be placed on the floor unless it is medically necessary for the patient’s safety and comfort. In all cases where restraints are used, there must be an order from a physician and documentation of why the restraint was necessary.

b.  Liquid oxygen tanks filled and ready for use;

a. Liquid oxygen generators (not filled and not usable)
b. Liquid oxygen tanks (filled and ready for use)

c. Inadequate training of healthcare personnel in wound care; and

d. Lack of knowledge about the importance of proper wound care.

e. Emergency oxygen tanks not properly maintained; last inspection was in 2016.

Patients were sleeping on bare mattresses due to a lack of access to bedding and linens.

Poor access to hygiene items can lead to a number of health issues, including skin infections, gastrointestinal illnesses, and even respiratory illnesses. To help improve access to hygiene items, it is important to ensure that people have access to clean water and soap for handwashing, as well as access to other hygiene items such as toilet paper, sanitary pads, and menstrual cups. Additionally, providing education on proper hygiene practices can help people understand the importance of these items and how to use them correctly. Finally, providing subsidies or free distribution of hygiene items can also help ensure that everyone has access to these essential items.

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20200514-CAF-JTFC-3350-OpLaser-20_01-20200529

This document contains the operational instructions for the CAF JTFC 3350 OpLaser 20 laser system. It is intended to provide guidance on the safe and effective use of this system.

1.0 Introduction
The CAF JTFC 3350 OpLaser 20 is a high power, pulsed laser system designed for industrial applications such as cutting, welding, and marking. The system consists of a control unit, laser head, and safety interlock switch.

2.0 Safety Precautions
The CAF JTFC 3350 OpLaser 20 must be operated in accordance with all applicable safety regulations and guidelines. All personnel operating the system must be trained in its proper use and wear appropriate protective equipment at all times when using the system.

3.0 Setup
Before using the CAF JTFC 3350 OpLaser 20, ensure that it is properly installed according to the manufacturer’s instructions. Ensure that all components are securely connected and that all safety interlocks are engaged before powering up the system.

4.0 Operation
When operating the CAF JTFC 3350 OpLaser 20, ensure that all personnel in the vicinity are wearing appropriate eye protection and other protective gear as required by local regulations or guidelines. Set up the workpiece on a stable surface and adjust any necessary parameters on the control unit before activating the laser head. When finished with an operation, turn off both the control unit and laser head before disconnecting any cables or components from either device.

5.0 Maintenance
Clean all components of the CAF JTFC 3350 OpLaser 20 regularly to prevent dust buildup which can interfere with its operation or cause damage to sensitive components over time. Inspect all cables for signs of wear or damage before each use and replace any damaged parts immediately to avoid potential hazards during operation of the system.