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
December 2, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 2, 2024
Observations: Licensing measured the water temperature of a tub on the first floor that was regularly used by persons in care. The temperature read 54 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. A plan for corrective action is to be submitted to Licensing by November 25, 2024. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required: Ensure that all furniture and equipment for use by persons in care 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 2, 2024
Observations: This item was brought forward from Follow Up Inspection dated November 14, 2024.Licensing observed a light fixture in one person in care's bedroom that was missing the protective cover which was accessible to the person in care. On November 25, 2024, Licensing observed a smoke detector that had been taken out, with wires hanging down that had been taped, on the first floor.
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 all employees have complied with the Province's Immunization and Tuberculosis Control Programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 2, 2024
Observations: This item has been carried forward from Routine inspection AD755A57-B466-4FD7-9807-4C564AD510CF dated November 10, 2022. Licensing was unable to audit staff files on this date.
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 the policies and procedures of the Medication Safety and Advisory Committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 25, 2024
Observations: Licensing audited three person in care's medications and Medication Administration Records (MARs). One person in care did not have multiple medications, on different dates, signed or coded for by staff on the MAR.
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 for each person in care, there is a record showing 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.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 25, 2024
Observations: Licensing audited three person in care's record. One person in care did not have a record of consent to be admitted into the community care facility.
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 a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 25, 2024
Observations: Licensing audited three person in care's records. One person in care was not weighed in September 2024 and one person was not weighed in February or March 2024.