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)
Follow-Up
May 9, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed two bath tubs which had non-slip mats.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 44(2)(a)
Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,
Corrective Actions Required: Ensure that if there are 50 or more persons in a community care facility, that the food services manager is a nutrition manager with the Canadian Society of Nutrition Management.
Corrective Actions Taken By Licensee: Licensee has submitted a an exemption request, which remains with Licensing as pending.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2024
Observations:
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 staff comply with the policies and procedures of the medication safety advisory committee.
Corrective Actions Taken By Licensee: Licensing audited the medication administration record and observed one medication for a person in care that was not signed for or coded by staff in April, 2024.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2024
Observations:
3030 - RCR 63(3)(c)(iii)
Description: A licensee must ensure that meals are provided by ongoing room tray service, if approved by the person in care’s medical practitioner or nurse practitioner
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed the care plans for two persons in care who previously received ongoing tray service and observed each care plan had been updated to reflect occasional tray service by request/due to illness only.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited one person in care's file and observed signed consent for admission.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 all persons in care have written consent to call a medical/nurse practitioner or ambulance in the case of accident or illness.
Corrective Actions Taken By Licensee: Licensing reviewed the files of two persons in care. Signed consents were observed to be included in the file of one person in care. Facility manager reports one person in care remains under the Public Guardian and Trustee of BC, and states the facility will submit an exemption request for same.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 9, 2024
Observations:
3070 - RCR 81(3)(e)(i)
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 an assessment of the nature of the risk of falling presented by the person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed one person in care's care plan which included a falls risk assessment.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing observed the care plan for one person in care which included a plan to follow up on any falls suffered by the person in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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: Licensing audited two medication carts and no expired medications were observed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: