Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)
Routine
March 22, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure that all rooms/common areas are maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2022
Observations: Licensing toured the facility on this date. One bedroom had plaster missing from the roof.
3010 - RCR 40(1)(a)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that regular performance reviews are completed to ensure they continue to meet the requirements of the RCR.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2022
Observations: Licensing audited three employee files. Two employee files did not have a regular performance review. One performance review was dated December 2018 and the other was dated March 2019.
3010 - RCR 40(1)(b)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: Ensure that regular performance reviews are completed to ensure they demonstrate competence for duties assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 22, 2022
Observations: Licensing audited three employee files. Two employee files did not have a regular performance review. One performance review was dated December 2018 and the other was dated March 2019.
3010 - RCR 68(4)
Description: A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Corrective Actions Required: Ensure that all employees comply with policies and procedures of Medication Safety & Advisory Committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 22, 2022
Observations: Licensing audited the electronic Medication Administration Record for March 15 to 22, 2022. On March 17, 2022 there was one person in care's medication that was not signed as administered as per medication policies.
3050 - RCR 62(2)(a)
Description: A licensee must ensure that each menu provides for each day, a nutritious morning, noon and evening meal, with each meal containing at least 3 food groups as described in Canada’s Food Guide,
Corrective Actions Required: Ensure that the menu provides nutritious breakfast/lunch/dinner with at least 3 food groups daily.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited the menu for the facility. The menu did not include breakfast.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that there are clear and up to date records of immunization status for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited four person in care's charts. One person in care did not have a record of immunization status kept.
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure that the consent for a person in care to be admitted or to continue to be accommodated in the community care facility, given accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited four person in care's charts. One person in care did not have a record of required Health Care Consent and Care Facility Admission.
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure there is a record for each person in care for consent to call medical/nurse practitioner or ambulance.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited four person in care's charts. One person in care did not have a record of written consent to call medical/nurse practitioner or ambulance.
3070 - RCR 81(3)(e)(iii)
Description: 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
Corrective Actions Required: Ensure that for those persons in care at risk of falling there is a plan addressing follow-up to falls suffered included in the care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 29, 2022
Observations: Licensing audited four person in care's care plans. One person in care who was at risk of falling did not have a plan to address following up to falls suffered.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that all employees have character references kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited three employee files. One employee file did not have character references kept.
3070 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that all employees have a record of employee compliance with the Province's immunization and TB control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing audited three employee files. One employee file did not have a record of immunization and tuberculosis.
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required: Ensure that there is ongoing planned program of physical/social/recreational activities suitable to needs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 5, 2022
Observations: Licensing observed the recreation calendar for March 2022. There was not a full calendar of ongoing planned activities.