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

13-May-2022

Subject

["Health and Safety","Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)"]

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

Code

Category/Description

3080 - RCR 69(1)(a) 
 

A licensee must ensure that a pharmacist packages all medications

Observation: Through the investigation process, Licensing determined the licensee did not ensure that a pharmacist packaged all medications.

Corrective action: Ensure that all medications are packaged by a pharmacist. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Action/s Required by Licensing: On July 29, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included a reminder to all new admissions that medications must be packaged by the pharmacy. This corrective action plan was reviewed and accepted by Licensing. On August 19, 2022 Licensee confirmed that the corrective action plan item was completed and implemented.

3080 - 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 the health, safety and dignity of persons in care

Observation: Through the investigation process, Licensing determined that the Licensee did not ensure that the facility was operated in a manner that would promote the health, safety and dignity of the persons 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 July 29, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: adding addendums to nursing practice so each floor knows what to do should any medications come in without being processed by the pharmacy. This corrective action plan was reviewed and accepted by Licensing. On August 19, 2022, Licensee confirmed that the corrective action plan item was completed and implemented.