30. Incident Reporting

All employees of JTC Staffing Solutions are responsible for immediately reporting all incidents regardless of how minor they may be. They must report the incident to their direct supervisor or director of care in the facility which they are currently working and then they should follow their reporting procedure. It is also a requirement to report the incident to the JTC Staffing Solutions office or on-call staff as soon as possible. Any employee who witnesses or becomes aware of or suspects any of the following must report it as soon as possible:

  • Improper/incompetent treatment or care of a resident
  • Unlawful conduct that affects or may affect a resident
  • Incidents that may cause physical, mental, or emotional harm to a resident or staff member, regardless of how slight
  • Abuse or neglect of a resident by anyone, including a staff or board member of the facility (suspected, witnessed or alleged), this includes misuse or misappropriation of resident property
  • Verbal complaints concerning resident care or operation of the facility
  • Breach of the facilities policies or procedures, including the Long-Term Care Health Act and its regulations
  • Any retaliation against a person for making a report under this policy or for disclosing anything to an inspector or the MOHLTC Director

In order to comply with the requirements of the Ontario Occupational Health and Safety Act, 1990 and the Workplace Safety and Insurance Act, 1997, each facility supervisor is responsible for ensuring that employees receive proper medical treatment if necessary and for investigating an accident or workplace injury for the purpose for implementing corrective action to minimize any opportunity for a recurrence of the accident.

Critical incidents as per the MOHLTC, is described as an occurrence that results in harm or risk of harm to the safety, security, welfare or health of a resident’s staff members as well as the safety and security of the Home itself. Examples of this include:

  • An emergent situation including loss of essential services, fire, unplanned evacuation, intake of evacuees or flooding
  • Unexpected or sudden death including a death resulting from an accident or suicide
  • A resident who is missing for less than three hours and returns with no injury or adverse change in condition
  • A resident who is missing three hours or more
  • A missing resident who returns with an injury or adverse change in condition, regardless of the length of time the resident was missing
  • An outbreak of a reportable or communicable disease as defined in the Health Protection Promotion Act
  • Contamination of the drinking water supply
  • An environmental hazard including breakdown or failure of the security system, security or well-being of residents for greater than six hours
  • Missing or unaccounted for controlled substances
  • An injury for which the person is taken to a hospital
  • A medication incident or adverse drug reaction for which the resident is taken to a hospital

Critical Incidents as per the Ministry of Labour is any injury to the staff of a serious nature that:

  • Places life in jeopardy
  • Produces unconsciousness
  • Results in substantial loss of blood
  • Involves fracture of a leg, arm, hand, or foot (not fingers or toes)
  • Involves amputation of a leg, arm, hand or foot (but not a finger or toe)
  • Consists of burns to a major portion of the body
  • Causes the loss of sight in an eye

A supervisor/manager/RN receiving any reports of alleged misconduct must notify the DOC/Administrator immediately upon receipt of the report (Section 24(1) of the LTCHA) and must understand that it is an offense under the LTCHA to discourage or suppress a mandatory report. The Administrator or DOC will report to the MOHLTC Director through the Critical Incident Reporting System or after hour’s pager.


All non-emergent complains must be reported directly to your superior at whichever home you are working in. in addition, you must report any and all complaints to the Plan A office. The following is a basic outline of the complaint policies to follow in a facility:

Definition of a Complaint:
An expression of dissatisfaction or a grievance in regards to actions, policies or procedures, by either an employee or a resident (theft, missing laundry, etc.).

When a verbal complaint has been made:

  • The person receiving the complaint will obtain as many details as possible.
  • An investigation will be initiated immediately.
  • If the verbal complaint can be resolved within 24 hours, the person receiving the complaint (or department manager) will respond verbally to the person making the complaint.
  • If no resolution has been made in 24 hours a written record of the investigation and outcome is then required.
  • A committee will review all complaints quarterly, analyze the information to determine any trends and develop an action plan to address them as necessary.
  • The action plan is reviewed again by the committee if actions have not been or are minimally effective, review the plan and revise.
  • This process will be repeated until effective results are achieved.
  • Complaint binders should be located in each nursing office with the complaint forms in them.

When a written complaint has been made:

All written complaints are to be forwarded to the Department Manager immediately. The manager will review the complaint and inform the Administrator. If required, the department manager may contact the author of the complaint to acquire further details. An investigation will then be initiated and it will include:

  • Interviews with the staff and/or the staff in the same unit
  • Interviews with the resident and/or other residents
  • Reviewing the documentation
  • Physically assessing the resident if it is required (nursing)
  • The administrator will inform the Regional Director of the investigation and the outcome.
  • Notes will be taken of all interviews, observations and other actions related to the investigation (witnessed statements should be written themselves and signed).
  • If the investigation is not completed within 6 days, the Administrator is required to contact the author of the complaint to keep them informed until a resolution is achieved.
  • A written response will include what the Home has done to resolve the complaint.
  • A copy of the written complaint will be forwarded to the appropriate regulatory person.
  • The complaint will be entered in the complaint log.