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
April 18, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 in the community care facility are safely and securely stored at all times.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: This item has been carried forward from Routine inspection 575187CE-6F8F-4100-B4D0-5B9263413F12 dated July 7, 2023. Licensing observed unsecured medications in two person in care's bedrooms.
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: May 18, 2024
Observations: Licensing audited the Electronic Medication Administration Record. There were eight dates in April 2024 where medications were not signed for or coded for as per the Medication Safety and Advisory Committee.
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required: Ensure that if a person in care has been determined at risk of leaving a community care facility without notification of an employee, there is a plan if the person in care leaves without notification, to locate the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 2, 2024
Observations: Licensing audited eighteen person in care's care plans. Three persons in care were at risk of elopement. All three care plans did not include a plan to address if the person in care leaves without notification, to locate the person in care.
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 monthly.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 31, 2024
Observations: Licensing audited eighteen person in care's weight records. Thirteen person in care's were missing some monthly weight records.
3080 - RCR 11(1)(b)
Description: A licensee, other than a licensee who provides a type of care described as Child and Youth Residential or Community Living, must display in a prominent place in the community care facility the most recent routine inspection record made under section 9 (1) (d) of the Act.
Corrective Actions Required: Ensure that the most recent routine inspection is displayed in a prominent place in the community care facility.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 18, 2024
Observations: Licensing toured the facility on this date. There was no previous inspections posted in the facility.