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 28, 2023
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 and 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: December 27, 2023
Observations: This contravention was carried over from the last Routine Inspection dated May 16, 2022. Manager stated that they have a construction staff installing wall boards to prevent continual wear and tear on the walls and to cover up the existing worn walls.
3010 - RCR 37(1)(e)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that a licensee must not employ a person in a community care facility unless the licensee or manager has obtained evidence that the person has complied with the Province's immunization and TB control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: This contravention was carried over from the last two Routine Inspections dated November 4, 2021 and May 16, 2022.
On March 28, 2023, Licensing reviewed 45 staff files and 9 files did not have record of immunization and TB results. 20 files were not accessible to Licensing to determine if records of immunization and TB results were on file.
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 the performance of each employee is reviewed regularly to ensure that the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: This contravention was carried over from the last Routine Inspection dated May 16, 2022.
On March 28, 2023, Licensing reviewed 45 staff files and 9 files did not have updated performance reviews. 20 files were not accessible to Licensing to determine if there were performance reviews were on file.
3060 - CCALA 7 (1)(b)(i)
Description: A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Required: Ensure the facility operates in a manner that promotes the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: This contravention was forwarded from the last two Routine Inspections dated November 16, 2021 and May 16, 2022. On March 28, 2023, Manager stated they were in the process of developing a process to ensure staff ensure utility rooms are locked and not accessible to persons in care.
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 that each person in care's record has consent in writing from the person in care or representative of the person in care to call a medical practitioner or ambulance in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: Licensing reviewed 30 person in care's records and 5 person in care records did not have consent to call a medical practitioner or ambulance in case of accident or illness.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: Licensing reviewed 30 person in care weight charts and 5 persons in care were missing monthly weights.
3070 - RCR 91(2)(b)
Description: In respect of a record referred to in this regulation, a licensee must keep a record other than one referred to in paragraph (a) in a place from which it can be retrieved within a reasonable time, on request,
Corrective Actions Required: Ensure that records can be retrieved within a reasonable time, on request.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 26, 2023
Observations: Licensing reviewed 45 staff files and 20 files were not accessible to Licensing to review. At the time of inspection, the Manager emailed the system program to follow up on getting access to the files. Licensing requested the Manager to notify Licensing once access to the file was in place.
3080 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored.
Corrective Actions Required: Ensure that all medications are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 29, 2023
Observations: Licensing viewed 30 person in care rooms and in 5 person in care rooms, medications and prescribed creams were left out on the bathroom counters in bedroom tables.
3080 - RCR 72(b)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 29, 2023
Observations: Licensing reviewed 30 person in care rooms and found one expired medication left out in 1 person in care room.