Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

Complaint Investigation

Inspection Information

Facility Type

Residential Care - 400

Received Date

20-Dec-2023

Subject

["Neglect","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]

Contraventions: A summary of the new contraventions found during the inspections are listed below.

Code

Category/Description

3030 - CCALA 7(1)(b)(i) 
 

A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care

Observation: Through the investigation process, Licensing determined that staff had provided 'care in the air' which is not an accepted practice.

Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On February 23, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: The Director of Care (DOC) and Assistant Director of Care (ADOC) reviewed policies regarding "care in the air" and provided education to staff about appropriate care as indicated in the care plans of person in care, staff were provided education on safe handling and proper use of slings and equipment, and, the DOC and ADOC completed random spot checks on care being provided. The corrective action plan was reviewed and accepted by Licensing. On March 27, 2024 Licensing received evidence that the training and spot checks on care had been completed.

3070 - CCALA 7(1)(b)(i) 
 

A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,

Observation: Through the investigation process, Licensing determined that staff did not complete accurate documentation of the care provided to persons in care.

Corrective action: Ensure the community care facility is operated in a manner that will promote the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On February 23, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: the Director of Care (DOC) and Assistant Director of Care (ADOC) provided random audits of documentation. This corrective action plan was reviewed and accepted by Licensing. On March 27, 2024 Licensing received evidence that the audits had been completed.

3010 - RCR 42(1)(b) 
 

A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene, in a manner consistent with the health, safety and dignity of persons in care.

Observation: Through the investigation process, Licensing determined that the Licensee did not have a sufficient numbers of employees on duty to assist persons in care with personal hygiene.

Corrective action: Ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to assist persons in care with activities of daily living, including eating, mobility, dressing, grooming, bathing and personal hygiene, in a manner consistent with the health, safety and dignity of persons in care. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On February 23, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that the Licensee continued hiring efforts to complete full staffing complement through utilizing a staffing agency and implemented a hiring plan to attract staff. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan.