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

20-Feb-2024

Subject

["Neglect"]

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

Code

Category/Description

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, about 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. Action/s Required by Licensing: On March 20 and April 9, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included that on March 14, 2024, there was a meeting with staff which reviewed the importance of documentation. This corrective action plan was reviewed and accepted by Licensing. On March 20, 2024, Licensing received a copy of the meeting agenda, as well as the attendance list for the meeting.

3070 - 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 (i) the health, safety and dignity of persons in care,

Observation: Through the investigation process, Licensing determined that the facility was not operated in a manner that promoted the health, safety, and dignity of persons in care, specifically related to documentation.

Corrective action: Ensure 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 March 20 and April 9, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: On March 14, 2024 there was a meeting with staff which reviewed the importance of documentation. The corrective action plan was reviewed and accepted by Licensing. On March 20, 2024, Licensing received a copy of the meeting agenda, as well as the attendance list for the meeting.

3030 - RCR 52(1)(a)(iii) 
 

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 March 20 and April 9, 2024, Licensee submitted a corrective action plan to Licensing. This corrective action plan included: On March 14, 2024 there was a meeting with staff which reviewed MOST M-1 Scores and interventions, specifically, when to call a physician and family, reviewed comfort care measures for persons in care, changes in condition of a person in care post-fall, and how staff should assess persons in care with dementia in terms of falls. The corrective action plan was reviewed and accepted by Licensing. On March 20, 2024, Licensing received a copy of the meeting agenda, as well as the attendance list for the meeting.