Complaint Investigation
Inspection Information
Facility Type
Residential Care - 400
Received Date
18-Mar-2022
Subject
["Health and Safety","Reporting (Includes issues such as not reporting, insufficient reporting, etc.)","Neglect","Dispute Resolution","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
Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify the parent or representative, or contact person, of the person in care,
Observation: Through the investigation process, Licensing determined that thee Licensee did not immediately notify the parent or representative, or contact person, of the person in care.
Corrective action: Ensure that if a person in care is involved in a reportable incident, the Licensee must immediately notify the parent or representative, or contact person, of the person in care. Action/s Required by Licensee: Licensee to submit a corrective action plan specific to the contravention. Action/s Required by Licensing: On June 1, 2022, the Manager submitted a corrective action plan to Licensing. This corrective action plan included: on June 1, 2022 a reminder email was sent to all staff about the importance of knowing in what manner and at what time a health representative for a person in care would be notified of a fall; in absence of this knowledge, the default was to call, and a copy of the fall policy and procedure, which included notifying the health representative in a timely manner, as well as prevention, risk assessments, communication and education, implementation of interventions, and individualized interventions was also included in the email to staff. This corrective action plan was reviewed and accepted by Licensing. On August 29, 2022 Management provided the following: Management confirmed staff reviewed documentation submitted from pathways to ensure the facility was safely able to admit persons in care, if it was unsafe to admit a person in care, they were to postpone admission, the Licensee and Island Health had systems in place for equipment loaning, and admission was delayed until the appropriate equipment was obtained by the facility, and in the event safe care was unable to be provided, the admission was declined.
A licensee must 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 safety and dignity of a person in care was not promoted. Specifically, that the person in care had no preventative measures in place for falls.
Corrective action: Ensure the community care facility operates 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 specific to the contravention. Action/s Required by Licensing: On June 1, 2022, the Manager submitted a corrective action plan to Licensing. This corrective action plan included: on June 1, 2022 a reminder email was sent to all staff about the importance of knowing in what manner and at what time a health representative for a person in care would be notified of a fall; in absence of this knowledge, the default was to call, and a copy of the fall policy and procedure, which included notifying the health representative in a timely manner, as well as prevention, risk assessments, communication and education, implementation of interventions, and individualized interventions was also included in the email to staff. This corrective action plan was reviewed and accepted by Licensing. On August 29, 2022 Management provided the following: Management confirmed staff reviewed documentation submitted from pathways to ensure the facility was safely able to admit persons in care, if it was unsafe to admit a person in care, they were to postpone admission, the Licensee and Island Health had systems in place for equipment loaning, and admission was delayed until the appropriate equipment was obtained by the facility, and in the event safe care was unable to be provided, the admission was declined.