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

19-Aug-2022

Subject

["Staffing (Includes issues such as suitability, insufficient levels, etc.)","Service Delivery Problem"]

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

Code

Category/Description

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 October 7, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: a wound care and bath audit was to be conducted weekly by the Director of Care (DOC), extra staff were scheduled to complete any missed care as required, agency staff were to be utilized as needed, nurses to work as Registered Care Aides (RCAs) to cover staff shortages and the DOC and Registered Nurse (RN) were to work on the floor when needed. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On February 24, 2023, Licensing observed adequate staffing levels at the facility and was informed by the Manager that all RCA positions had been filled.

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

Corrective action: 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. 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 7, 2022, Licensee submitted a corrective action plan to Licensing. The corrective action plan included: extra staff were scheduled to complete any missed care as required, agency staff were to be utilized as needed, nurses were to work as Registered Care Aides (RCAs) to cover staff shortages and the Director of Care (DOC) and Registered Nurse (RN) were to work on the floor when needed. The corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. On February 2, 2023, Licensing was made aware that the Licensee had hired an Assistant Director of Care (ADOC) who started at the facility on January 30, 2023 and on February 24, 2023, Licensing observed adequate staffing levels at the facility and was informed by the Manager that all RCA positions had been filled.