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
January 26, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure that all policies and procedures are reviewed and, if necessary, revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 26, 2024
Observations: Licensing reviewed facility policy and procedure manual which was last reviewed in 2021.
3030 - RCR 83(4)(b)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must immediately seek the advice of a health care provider if the person in care has experienced, unintentionally, a significant change in weight,
Corrective Actions Required: Ensure to immediately seek advice of a health care professional if the person in care has experiences a significant change in weight.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 26, 2024
Observations: Licensing reviewed five persons in care's weight records. One person in care had a significant weight gain over three months. Staff stated that a weight loss plan was implemented without the involvement of a Dietician. Licensing audited the records for the person in care and saw no involvement from a Dietician or Physician in regards to the increase in weight.
3070 - RCR 81(3)(c)(i)
Description: A care plan must include all of the following: a nutrition plan that assesses a person in care’s nutrition status,
Corrective Actions Required: Ensure that all persons in care have a nutrition care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 26, 2024
Observations: Licensing reviewed the care plans of five persons in care. All persons in care did not have a nutrition care plan.
3070 - RCR 81(4)(a)
Description: A licensee must ensure that the implementation of each care plan is monitored on a regular basis to ensure proper implementation,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By:
Observations:
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required: Ensure that each care plan is reviewed and if necessary modified if there is a substantial change in circumstances of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 26, 2024
Observations: Licensing reviewed the care plans of five persons in care. One care plan was not reviewed or modified following a substantial change in the health status of a person in care.
3070 - RCR 81(4)(b)(ii)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year
to ensure it continues to meet the needs and preferences, and is compatible with the abilities, of the person in care who is the subject of the care plan
Corrective Actions Required: Ensure that each care plan is reviewed and, if necessary, modified if there is no substantial change in the circumstances of the person in care, at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 26, 2024
Observations: Licensing reviewed the care plans of five persons in care. All five care plans had not been reviewed annually.
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 per month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 26, 2024
Observations: Licensing reviewed the weights of five persons in care. Weights had not been recorded monthly.