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

28-Jul-2022

Subject

["Emotional Abuse","Physical Abuse","Neglect","Physical Plant/Equipment (Includes issues such as cleanliness, state of repair, insufficient quantity of supplies, smoking/vaping etc.)"]

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

Code

Category/Description

3070 - RCR 81(3)(e)(iii) 
 

A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for following up on any falls suffered by a person in care

Observation: Through the investigation process, Licensing determined that a person in care, who was at risk for falls, did not have a follow up to falls included in their care plan.

Corrective action: Ensure that if a person in care is prone to falling, that they have a fall prevention plan which addressed a plan to follow up on falls suffered by a person 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 August 24, 2022, Licensee submitted a corrective action plan to Licensing specific to the contravention. The corrective action plan included that the person in care had passed away, a process was implemented by nursing staff to ensure that all persons in care who were at risk for falls had a plan to follow up to falls suffered included in the care plan, the Director of Care reviewed weekly reports which included a review of fall care plans for persons in care, a Professional Practice Meeting was scheduled for August 30, 2022 with nursing staff which reviewed the new process and minutes from the meeting were posted and emailed to nursing staff. This corrective action plan was reviewed and accepted by Licensing. Licensing to review and monitor this corrective action plan. Follow Up Inspection Required. On November 17, 2022, Licensing received copies of the Professional Practice Meeting, dated August 30, 2022 with multiple staff in attendance, which reviewed the process and policies for post fall management and confirmation that meeting minutes was mailed to all nurses and posted in the medication room on each floor.