Copernicus Lodge (66 Roncesvalles Avenue, Toronto) is a non-profit healthcare organization providing services for approximately 230 residents in long-term care, 200 independent tenants, and up to 20 adult day program clients daily.
Inspection Reports for Copernicus Lodge
Our research team carefully reviewed and summarized inspection reports for Copernicus Lodge. You can read the original copies of the reports in the Government of Ontario website.
July 2023
The inspection occurred between June 26 – 30, 2023, and July 4, 2023, and focused on Critical Incident System (CIS) intakes related to falls, injuries, and improper interventions.
One key non-compliance issue identified is related to the development of 24-hour admission care plans for residents at risk of falling. The licensee, Copernicus Lodge, failed to ensure that such plans, including interventions to mitigate fall risks, were developed and communicated to direct care staff within 24 hours of a resident’s admission to the home. This oversight placed residents at potential risk of injury.
Another non-compliance issue involves the completion of the Physiotherapy Initial Assessment within 14 days of a resident’s admission, as required by regulations. In this case, the assessment was not completed as per the home’s policy, potentially jeopardizing residents’ care needs.
March 2023
This is an Inspection Report occurred between February 21 and March 15, 2023, and it included various intake types, such as complaints, duty to protect, and fall-related incidents. Multiple Inspection Protocols were employed to evaluate different aspects of care, including skin and wound prevention, continence care, infection prevention and control, and falls prevention.
The report highlights several instances of non-compliance. The most severe non-compliance noted was a case of physical abuse of a resident by a staff member. The Director of Care acknowledged the abuse, which demonstrates the severity of the incident.
One issue related to infection prevention and control was remedied by the licensee before the inspection concluded. This involved a lapse in ensuring all required public health measures were implemented, particularly regarding the use of surgical masks during entrance screening.
Another non-compliance issue concerned the clarity of written plans of care. An error in transcribing an order led to a lack of clear direction for staff, which is crucial for effective care. Although this did not result in harm, it emphasized the importance of precise instructions.
A third non-compliance issue involved the timely revision of care plans when residents’ needs changed. In this case, an identified device order was discontinued, but the plan of care was not updated accordingly. While it didn’t harm the resident, it highlighted the need for accurate and up-to-date care plans.
The report also includes non-compliance related to the provision of care as specified in the plan of care. In one instance, a specific symptom prevention order was not followed, putting the resident at risk.
Additionally, the report highlights non-compliance with forwarding written complaints to the Director, which is a legislative requirement. In this case, written complaints were not forwarded promptly.
Lastly, non-compliance with serving food and fluids at the correct temperature during meal service was identified, particularly in the case of milk being served too early before mealtime.
December 2022
This is an Inspection Report was conducted under the Critical Incident System (CIS) inspection type. Multiple intakes related to falls, injuries, and unknown causes were investigated during this inspection.
The report highlights several instances of non-compliance, with one instance being remedied during the inspection. The remedied issue involved a staff member not following routine hand hygiene practices as required by the infection prevention and control (IPAC) program. Specifically, a staff member failed to perform hand hygiene between caring for two residents during meal tray delivery. This posed a risk of infectious disease transmission, but the issue was resolved promptly.
The second non-compliance issue pertains to pain management. The home failed to comply with the pain management program to identify and manage pain for a resident. Despite the resident’s complaints of pain, pain assessments were not consistently performed as required by the Pain Management Program Policy. This led to the risk of unmanaged pain for the resident.
February 2022
An inspection was completed by Inspector Noreen Frederick as part of a Complaints Inspection.
- Improper Positioning During Feeding: The licensee failed to ensure that residents #010 and #011 were safely positioned while being fed. Resident #010 required one-person total assistance with feeding, but the Personal Support Worker (PSW) student fed the resident at a 30-degree angle, leading to coughing. Resident #011 also required one-person total assistance with feeding, but PSW #126 fed the resident at a 45-degree angle. These positions were deemed unsafe. The home’s Feeding Techniques policy and the Director of Care (DOC) recommended positioning residents upright between 60-90 degrees while feeding. The failure to safely position residents during feeding posed a risk of aspiration.
- Unrevised Care Plans: The licensee failed to ensure that resident #002’s care plan was revised after a reassessment. The resident’s care plan indicated the use of an assistive device, but the resident did not have one. Nursing Supervisor #102 stated that the resident was reassessed for the assistive device, which was discontinued, but the care plan was not revised accordingly. This oversight posed a risk of resident #002 receiving improper care.
Another inspection was completed as part of the Critical Incident System (CIS). Several issues were identified by the inspectors.
- Failure to Ensure Staff Participation in Infection Prevention and Control (IPAC) Program: The licensee failed to ensure that all staff participated in the implementation of the home’s Infection Prevention and Control (IPAC) program related to residents’ hand hygiene. During lunch observations on February 7 and 8, 2022, it was observed that Registered Nurse (RN) #105 and several Personal Support Workers (PSWs) did not offer or provide assistance with hand hygiene to residents before lunch. This practice did not align with the home’s hand hygiene program policy, which required staff to assist residents with hand hygiene before meals. The failure to follow proper hand hygiene protocols placed residents at risk of infection transmission.
In response to this non-compliance issue, a Voluntary Plan of Correction (VPC) was requested from the licensee to prepare a written plan for achieving compliance with staff participation in the IPAC program.
September 2021
The inspection falls under the category of a Critical Incident System inspection. During the inspection, non-compliance issues were identified, leading to the issuance of Compliance Orders.
- Bed Rail Usage: The licensee failed to ensure that care set out in the plan of care was provided to three residents as specified in the plan related to bed rail use. Bed rails were observed in use for three residents without them being assessed for the use of bed rails and without it being specified in their care plans. This posed an increased risk of entrapment and injury for residents. The licensee was ordered to conduct audits over three months to identify any bed rails in use without proper assessment and documentation.
- Lack of Written Description: The licensee also failed to ensure that there was a written description of the personal support services (PSS) and nursing program. Despite having these programs in place, there was no written terms of reference for them. The licensee was ordered to develop written descriptions for these programs.
- Temperature Monitoring: The licensee failed to ensure that the temperature was measured and documented in writing in one resident common area on every floor of the home as required by regulations. Additionally, the temperatures were not documented as frequently as required, with some checks missing during specific time intervals. The licensee was ordered to ensure proper temperature monitoring and documentation.
Three Written Notifications, one Voluntary Plan of Correction, and one Compliance Order were issued as a result of the inspection findings.