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
July 7, 2023
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 all medications 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: July 14, 2023
Observations: This item has been carried forward from Routine inspection D9CC2D6E-21DF-4337-917D-62F8AC1E9886 dated September 16, 2022. Licensing observed unsecured medications in two person in care's bedrooms.
3010 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references
Corrective Actions Required: Ensure all staff files contain character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 7, 2023
Observations: This item has been carried forward from Routine inspection D9CC2D6E-21DF-4337-917D-62F8AC1E9886 dated September 16, 2022. Licensing audited 25 staff files. Three files did not contain character references.
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure all staff files contain immunization records.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 7, 2023
Observations: Licensing audited 25 staff files. Two staff files did not contain immunization records.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure all person in care binders contain evidence of compliance with the Provincial immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 7, 2023
Observations: This item has been carried forward from Routine inspection D9CC2D6E-21DF-4337-917D-62F8AC1E9886 dated September 16, 2022. Licensing audited 19 person in care binders. Three person in care binders did not contain evidence of compliance with the Provincial tuberculosis control program.
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: Ensure all persons in care have a plan related to following up on any falls suffered by a person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 7, 2023
Observations: Licensing audited 19 person in care files. 14 files did not contain information related to a plan for following up on any falls suffered by a person in care.
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: Ensure all expired medications are returned to the dispensing pharmacy.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 14, 2023
Observations: Licensing audited two medication stations. Licensing observed two expired medications.