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
May 2, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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 performance of each employee is reviewed regularly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: June 2, 2023
Observations: Licensing observed five staff files that did not have updated performance reviews.
3030 - RCR 63(3)(c)(ii)
Description: A licensee must ensure that meals are provided by ongoing room tray service, if by ongoing room tray service, if indicated in the care plan of a person in care,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
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:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations:
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 care plan must have a nutrition plan that assesses nutrition status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 8, 2023
Observations: Licensing reviewed five care plans and one care plan did not have a nutrition plan that assessed person in care's nutrition status.
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 substantial change in the 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: May 8, 2023
Observations: Licensing observed one care plan that was not updated when the person in care no longer required ongoing food tray service. Management stated that the person in care no longer received ongoing food tray service.
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 all medications are safe and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 2, 2023
Observations: Licensing observed one person in cares bathroom which had a barrier cream left out. Licensing observed the PCA room unlocked and there were two clear storage containers sitting on a table with all persons in care prescribed topical medications inside the containers. There were no staff in the room at the time.