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

07-Oct-2022

Subject

["Access by Others (Includes access to parents, family, others)","Dispute Resolution"]

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

Code

Category/Description

3030 - RCR 52(1)(a)(i) 
 

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 course of the investigation process, Licensing determined that a licensee did not ensure that a person in care, was not, while under the care and supervision of the licensee, 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 specific to the contravention. Action/s Required by Licensing: On November 28, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: all nursing staff completed education on reportable incidents and a person in care's family member met with the facility on December 6, 2022 and reviewed emotional abuse, respectful behaviors and communication. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On December 9, 2022 and January 4, 2023, Licensing received a letter summarizing the meeting with the person in care's family and confirmation of the completed staff training on January 4, 2023.

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 course of the investigation process, Licensing determined that the Licensee did not immediately notify a medical health officer, in the form and in the manner required, when a person in care was involved in a reportable incident.

Corrective action: Ensure that the Licensee immediately notifies a medical health officer, in the form and in the manner required, when a person in care is involved in a reportable incident. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On November 28, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: all nursing staff completed education on reportable incidents. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On January 4, 2023, Licensing received confirmation of the completed staff training.

3020 -RCR 85(1)(d) 
 

A licensee must do all of the following: ensure that policies are implemented by employees.

Observation: Through the course of the investigation process, Licensing determined that policies were not implemented by employees.

Corrective action: Ensure that policies are implemented by employees. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On November 28, 2022 Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a person in care's representative completed an updated release of person in care form to include anyone not authorized to remove the person in care from the facility. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On December 6, 2022. Licensing received a copy of the revised release of person in cares form.