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

23-Sep-2022

Subject

["Staffing (Includes issues such as suitability, insufficient levels, etc.)","Medication (Includes issues such as missing, inappropriate use/overuse of medications, errors, etc.)","Suitability of Manager or Suitability of Licensee"]

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

Code

Category/Description

3010 - RCR 42(1)(a) 
 

A licensee must ensure that, at all times, the employees on duty are sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of the persons in care,

Observation: Through the investigation process, Licensing determined that the Licensee did not have employees sufficient in numbers, training and experience to meet the needs of the persons in care.

Corrective action: Ensure that there are employees sufficient in numbers, training and experience to meet the needs 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 November 9, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: a nurse on call schedule was implemented, nursing staff were emailed with an update to the Manager Support schedule on November 3, 2022 and a cooperate nurse was scheduled overnights effective November 14, 2022. This corrective action plan was reviewed and accepted by Licensing. On November 9, 2022, Licensing received a copy of the on-call nursing schedule.

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 operate the community care facility in a manner that promoted the health, safety and dignity of the persons in care. Specifically, regarding the availability of oxygen prongs for persons in care.

Corrective action: Ensure that the Licensee operates the community care facility 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 November 9, 2022, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: emergency supplies were available to staff and an email was sent to all staff notifying them how to access supplies. This corrective action plan was reviewed and accepted by Licensing. On November 9, 2022, Licensing received a copy of the email.