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

10-Mar-2022

Subject

["Nutrition and Food Service (Includes issues such as consistency, quantity, quality, feeding assistance, timing, etc.)","Staffing (Includes issues such as suitability, insufficient levels, etc.)"]

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

Code

Category/Description

3070 - RCR 82 
 

A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care’s care plan.

Observation: Through the investigation process, Licensing determined that the Licensee had not ensured that the care and supervision of a person in care was consistent with the terms and conditions of the person in care's care plan. Specifically with regards to food size and texture.

Corrective action: Ensure that the care are supervision of a person in care is consistent with the terms and conditions of the person in care's care plan. 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 specific to the contravention. Action/s Required by Licensing: On April 25, 2022, Manager submitted a corrective action plan to Licensing. This corrective action plan included: on March 11, 2022, kitchen staff received in-service training on food textures, the Dietitian would run periodic sessions for new staff as required, the facility would ensure that personnel were correctly trained for their assigned duties, if staff were not trained they would not be assigned to work on the floor with persons in care. This corrective action plan was reviewed and accepted by Licensing. On September 23, 2022, Licensee provided the following: Licensee confirmed that the in-services for dietary aides had been completed, training was provided to new hires related to diet textures, and staff sign in sheets related to in-service training completed were submitted to Licensing.

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 employees on duty were not sufficient in numbers, training and experience, and organized in an appropriate staffing pattern, to meet the needs of 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 specific to the contravention. Action/s Required by Licensing: On April 25, 2022, Manager submitted a corrective action plan to Licensing. This corrective action plan included: on March 11, 2022, kitchen staff received in-service training on food textures, the Dietitian would run periodic sessions for new staff as required, the facility would ensure that personnel were correctly trained for their assigned duties, if staff were not trained they would not be assigned to work on the floor with persons in care. This corrective action plan was reviewed and accepted by Licensing. On September 23, 2022, Licensee provided the following: Licensee confirmed that the in-services for dietary aides had been completed, training was provided to new hires related to diet textures, and staff sign in sheets related to in-service training completed were submitted to Licensing.