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

19-Dec-2022

Subject

["Neglect","Recordkeeping (Includes issues such as not keeping records, insufficient records, care planning issues, health care consent, admission records.)"]

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 licensee did not operate the community care facility in a manner that promoted the health, safety and dignity of persons in care. Specifically, that staff did not complete daily documentation of care for a person in care.

Corrective action: Ensure that 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 14, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a memo that was distributed on January 3, 2023, reminding staff of documentation and task charting, a meeting was held with staff on February 1, 2023 regarding paper and electronic documentation, staff were to review and sign off on Focus Charting and Charting by Exemption policy by February 19, 2023, the Manager was to conduct ongoing chart compliance audits, and electronic charting was updated to include bathing tasks on February 10, 2023. The corrective action plan was reviewed and accepted by Licensing. On April 18, 2023, Licensing received a copy of the signed staff education record which confirmed continued auditing was in place, and that most staff had completed their review of Focus Charting and Charting by Exemption, other than regular night staff and some casual staff. Education remained in process for the outstanding staff.