Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
15-Sep-2022
Subject
["Neglect","Emotional Abuse"]
Contraventions: A summary of the new contraventions found during the inspections are listed below.
Code
Category/Description
A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Observation: Through the investigation process, Licensing determined that the care plan for a person in care had not been updated as care needs changed including fall risk.
Corrective action: Ensure that care plans for persons in care are reviewed and modified when there is a substantial change in their care needs. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 1, 2023, Licensee submitted a corrective action plan to Licensing. The corrective action plan included that a person in care's care plan was to be revised to include falls. This corrective action plan was reviewed and accepted by Licensing. On December 13, 2022, Licensing received the person in care's revised care plan which included falls.
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: emotional abuse
Observation: Through the investigation process, Licensing determined that a person in care was subjected to emotional abuse.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to emotional abuse. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 1, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a staff member's employment was terminated and they were reported to the BC Care Aide Registry, education was provided to staff on the Resident Bill of Rights, Preventing Abuse and Neglect and Zero Tolerance for Abuse and Neglect policies, the Manager was to continue education at orientation, staff meeting and huddles ongoing. The corrective action plan was reviewed and accepted by Licensing. On May 16, 2023, Licensing confirmed by email that ongoing education was being provided to staff.
A licensee must do all of the following: ensure that policies are implemented by employees.
Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that policies were implemented by employees.
Corrective action: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 1, 2022, Licensee submitted a corrective action pan to Licensing. The corrective action plan included: a review of the Declaration of Family Member Relationship policy which was completed with all staff, with sign off, on December 9, 2022. The corrective action plan was reviewed and accepted by Licensing. On December 13, 2022, Licensing received a copy of the policy which staff had signed.
A licensee must ensure that a person in care is not, while under the care or supervision of the licensee subjected to any of the following types of abuse or neglect, as described in section 1 of Schedule D: neglect
Observation: Through the investigation process, Licensing determined that a person in care was subjected to neglect.
Corrective action: Ensure that a person in care is not, while under the care or supervision of the licensee, subjected to neglect. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 1, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a staff member's employment was terminated and they were reported to the BC Care Aide Registry, education was provided to staff on the Resident Bill of Rights, Preventing Abuse and Neglect and Zero Tolerance for Abuse and Neglect policies, the Manager was to continue education at orientation, staff meeting and huddles ongoing. The corrective action plan was reviewed and accepted by Licensing. On May 16, 2023, Licensee confirmed that ongoing education was being provided to staff.
A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.
Observation: Through the investigation process, Licensing determined that the care plan for a person in care had not been implemented.
Corrective action: Ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On December 1, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: that care plans and Resident Days were to be reviewed and updated at each MDS-RAI assessment, care conference, and as needed when the person in care's health status has changed, care plans were to be discussed amongst all disciplines to ensure that the person in care's individualized wishes were being honored, this practice was to be ongoing, and a person in care's care plan was updated. The corrective action plan was reviewed and accepted by Licensing. On December 13, 2023, Licensing received a copy of the person in care's care plan.
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 did not demonstrate the skills and abilities to carry out the duties as assigned.
Corrective action: Ensure the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care, Specifically, that all staff have the character and skills necessary to carry out the duties assigned. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to this contravention. Action/s Required by Licensing: On December 1, 2022, licensee submitted a corrective action plan to Licensing. The corrective action plan included: a staff member's employment was terminated and they were reported to the BC Care Aide Registry, education was provided to staff on the Resident Bill of Rights, Preventing Abuse and Neglect and Zero Tolerance for Abuse and Neglect policies, the Manager was to continue education at orientation, staff meeting and huddles ongoing. The corrective action plan was reviewed and accepted by Licensing. On May 16, 2023, Licensing confirmed that ongoing education was being provided to staff as a refresher and on hire.