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

12-Sep-2024

Subject

["Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)"]

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

Code

Category/Description

3050 - RCR 66(1) 
 

A licensee must ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada’s Food Guide and the person in care’s nutrition plan.

Observation: Through the investigation process, Licensing determined that a person in care did not receive adequate food to meet their personal nutritional needs based on the person in care's nutrition plan.

Corrective action: Ensure that each person in care receives adequate food to meet their personal nutritional needs, based on Canada's Food Guide and the person in care's nutrition 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 October 25, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included an update to the person in care's nutrition care plan, and staff were reminded to follow the diet protocols and to document progress daily. The corrective action plan was reviewed and accepted by Licensing. On December 3, 2024, Licensing was notified that the person in care no longer resided at the facility and moving forward staff were to review and update nutrition care plans and seek consultation with a Registered Dietician and implement their direction.

3050 - RCR 62(2)(c)(i) 
 

A licensee must ensure that each menu provides a variety of foods, taking into consideration the nutrition plan of each person in care and the nutrition needs, age, gender and level of activity of the persons in care

Observation: Through the investigation process, Licensing determined that the menu did not take into consideration the nutrition plan of each person in care and the nutrition needs, age, gender, and level of activity of the persons in care.

Corrective action: Ensure that the menu provides a variety of foods, taking into consideration the nutrition plan of each person in are and the nutrition needs, age, gender, and level of activity of the 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 October 25, 2024, the Licensee submitted a corrective action plan to Licensing. The corrective action plan included an immediate review and update of the menu followed by a full update by the dietician by November 29, 2024. This corrective action plan was reviewed and accepted by Licensing. On December 3, 2024, Licensing was notified that the person in care had moved to another location prior to November 29, 2024 and the dietician did not attend to review the menu at the facility as planned.

3070 - RCR 77(2)(c) 
 

Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer

Observation: Through the investigation process, Licensing determined that the licensee did not immediately notify a medical health officer, in the form and in the manner required by the medical health officer when a person in care was involved in a reportable incident.

Corrective action: Ensure that if a person in care is involved in a reportable incident, the licensee immediately notifies a medical health officer, in the form and in the manner required by the medical health officer. Action/s Required by Licensee: Licensee to submit a corrective action plan to Licensing specific to the contravention. Actions Required by Licensing: On October 25, 2024, Licensee submitted a corrective action plan to Licensing. The corrective action plan included staff education regarding the reporting of incidents to Licensing in a timely manner had occurred. This corrective action plan was reviewed and accepted by Licensing.

3070 - RCR 82 
 

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 and supervision of a person in care was not consistent with the terms and conditions of the person in care's care plan.

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 Licensee: On October 25, 2024, Licensee Contact submitted a corrective action plan to Licensing. The corrective action plan included an update to the care plan of a person in care and staff reminded to review the updated care plan, follow the specific diet protocol for a person in care, and to document progress daily. This corrective action plan was reviewed and accepted by Licensing. On December 3, 2024, Licensing was notified that the person in care no longer resided at the facility and moving forward staff were to review and update nutrition care plans and seek consultation with a Registered Dietician and implement their direction.