Fairview Lodge (632 Dundas Street West, Whitby) is owned and operated by Durham Region. There are approximately 200 beds.
Inspection Reports for Fairview Lodge
Our research team at Caring Magazine carefully reviewed and summarized inspection reports for Fairview Lodge. You can read the original copies of the reports in the Government of Ontario website.
August 2023
The inspection report highlights several critical issues and non-compliance areas observed during the inspection conducted from July 13 to 26, 2023.
The inspection, led by Elaina Tso with additional inspectors Eric Tang, Ana Best, and Vernon Abellera, focused on various critical incidents and applied relevant protocols such as Skin and Wound Prevention and Management, Infection Prevention and Control, Prevention of Abuse and Neglect, Responsive Behaviours, and Falls Prevention and Management.
- Non-Compliance in Skin and Wound Care: The licensee failed to ensure necessary assessments for residents with altered skin integrity. A Registered Dietitian (RD) was not involved as required, and registered nursing staff did not conduct the mandated “Head to Toe Skin Assessment tool”. This failure increased risks for impaired skin integrity and delayed wound healing.
- Non-Compliance in Plan of Care: The licensee did not apply a fall prevention intervention for a resident as specified in their care plan. This oversight posed a risk of further injury to the resident.
- Non-Compliance in Weekly Reassessments: Two residents with altered skin integrity were not reassessed weekly by registered nursing staff, as required. This lack of reassessment could have led to prolonged wound healing and delays in treatment.
June 2023
The inspection, conducted by lead inspector Amanda Belanger, reveals several non-compliance issues. The inspection, both on-site (May 15-18) and off-site (May 22-25), covered various complaints and critical incidents.
- Non-Compliance in Duty to Report: The licensee failed to report to the Director an incident where a resident stated they had been hit, potentially involving visitor-to-resident abuse. Although there was minimal risk of harm, the failure to report such incidents is a serious oversight.
- Non-Compliance in Air Temperatures: The home did not measure or document the temperature in one common area on every floor, including lounges, dining areas, or corridors. This was confirmed by the Supervisor of Environmental Services. While there was minimal risk due to no extreme heat conditions, it is crucial to monitor these areas for resident comfort and safety.
- Non-Compliance in Resident Discharge Requirements: In the discharge of resident #001, the licensee failed to consider alternatives before the discharge, collaborate with appropriate coordinators for alternative arrangements, and involve the resident or Substitute Decision Maker (SDM) in the discharge planning. This oversight indicates a lack of thorough process adherence in handling resident discharges.
January 2023
The inspection, conducted by lead inspector Waseema Khan, focuses on a critical incident involving a resident.
The licensee failed to inform the Director of an incident involving a resident within the required timeframe. The incident occurred on March 17, 2022, but was not reported to the Ministry of Health until March 21, 2022. Additionally, the after-hours pager, which should have been used for immediate notification, was not contacted.
Critical Incident System (CIS) report indicated that the incident resulted in significant injury to a resident, necessitating hospital transfer and a notable change in their health status. The Director of Care (DOC) and Resident Care Coordinator (RCC) acknowledged the delay in reporting the incident.
April 2022
The inspection, conducted by Heath Heffernan was a response to complaints regarding air temperatures, medication administration, and staffing adequacy.
The licensee failed to properly document air temperatures in the facility. The specific requirement violated mandates the documentation of air temperature at least once every morning, afternoon (between 12 p.m. and 5 p.m.), and evening or night.
The inspection revealed that the temperature documentation from the Building Automated System (BAS) did not specify which rooms the temperatures were taken from. It only showed trends for the lowest temperatures in certain areas such as dining rooms and resident rooms in the east and west buildings.
The manager indicated they were unable to access written air temperature records specific to resident bedrooms in different parts of the home or one resident common area on each floor, as required by regulations.
A Written Notification (WN) was issued for the non-compliance regarding air temperature documentation. A Voluntary Plan of Correction (VPC) was also requested by the Ministry to ensure future compliance with the temperature measurement and documentation requirements.
January 2022
The inspection, conducted by Chantal Lafreniere and Sarah Gillis, was a Proactive Compliance Inspection. The inspection involved thorough evaluation and discussions with a wide range of staff and residents. The focus areas included Infection Prevention and Control, Medication, Nutrition and Hydration, Personal Support Services, and other crucial care aspects.
- Infection Prevention and Control (IPAC): There were multiple instances of non-compliance related to IPAC, including failure to properly use Personal Protective Equipment (PPE), lack of appropriate signage for isolation precautions, and inadequate hand hygiene practices.
- Plan of Care: The inspection found failures in following specific care plans for residents, particularly in areas like incontinence management and assistance with eating and drinking.
- Medication Policy Compliance: Issues were identified with the storage of narcotics, including improper storage of controlled substances, which posed risks of medication mismanagement.
- Nutrition Care and Hydration Programs: There were shortcomings in monitoring and evaluating food and fluid intake for residents with identified nutritional and hydration risks.
- Dining and Snack Service: The inspection found that food and fluids were not always served at safe and palatable temperatures, and there were lapses in ensuring that residents who required assistance with eating or drinking were served appropriately.
Compliance orders were issued to address the identified non-compliances, particularly focusing on improving IPAC practices, ensuring adherence to residents’ care plans, properly handling and storing medications, and enhancing food service protocols.
May 2021
Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.
Critical Incident Inspection
The inspection was a Critical Incident System inspection, focusing on a medication incident involving an adverse drug reaction that affected a resident of the facility.
- Plan of Care: The staff failed to collaborate effectively regarding a resident’s assessment after a medication error. This lack of collaboration led to inconsistent and incomplete assessments and communications about the incident, which increased the risk to the resident’s health.
- Administration of Drugs: A critical medication error occurred when a Registered Practical Nurse (RPN) administered medication prescribed for one resident to another. This incident highlighted the need for improved medication administration practices, including verifying the identity of residents before administering medications.
- Medication Incidents and Adverse Drug Reactions: The facility did not document the medication incident and the adverse drug reaction adequately. The initial documentation failed to include a complete list of the wrongly administered medications and the immediate actions taken to assess and maintain the affected resident’s health.
Critical Incident Inspection
The inspection, conducted by Moses Neelam, focused on several critical incidents. The inspection covered a range of issues, including COVID-19 related infection control practices, incidents of physical abuse between residents, multiple cases of resident falls leading to significant changes in health, and incidents of alleged responsive behaviors, emotional and verbal abuse of a resident by another resident.
The main non-compliance issue found during this inspection related to the home’s hand hygiene program. The licensee did not ensure adequate participation by staff in the hand hygiene program, especially in assisting residents with hand hygiene before and after meals. Observations and interviews indicated that multiple residents did not receive assistance for hand hygiene as required, thereby increasing their risk for acquiring pathogens.
September 2020
Critical Incident Inspection
The inspection, conducted by Jennifer Nicholls and Tracy Muchmaker, was a Critical Incident System inspection. The inspection covered incidents related to falls prevention and management, and an unexpected death.
The main issue of non-compliance found during this inspection was related to the Falls Prevention and Management policy of the home. The licensee did not ensure compliance with this policy for a resident known to be at high risk of falls. This resident had previously experienced a fall that resulted in injury and a change in their health status. Despite acknowledging the resident’s high risk, no new falls prevention strategies were initiated after the last fall, indicating a lapse in adhering to the Falls Prevention and Management policy.
Complaints Inspection
During the course of this inspection, Non-Compliances were not issued.