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

28-May-2024

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

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 the facility was not operated in a manner that would promote the health, safety, and dignity of persons in care. Specifically related to wound care documentation for a person 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 September 6 and 10, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a staff received education on the facility's Focus Charting and Charting by Exception policies, as well as Charting with the Park Place i-Learn Tool during the Clinical Practice Meeting on August 2, 2024; the Manager would continue to monitor a staff's progress notes and wound care documentation until November 1, 2024, the staff would complete a wound care program by the end of December 2024 and one staff remained on extended leave and would be given the same education upon return. This corrective action plan was reviewed and accepted by Licensing. On December 11, 2024, Licensing received staff sign-off sheets for wound care education on August 2, 2024, confirmation that wound care and progress note audits for the staff were completed and satisfactory, the wound care course was completed by one staff and the second staff was enrolled in the wound care program.