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
November 5, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 26, 2021
Observations: Licensing audited the electronic medication administration record from October 29-November 5 2021. One person in care had a medication on scheduled on October 31, 2021 that was not signed for.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure to have clear and up to date records of immunization kept for each person in care. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 26, 2021
Observations: Licensing audited three persons in care's charts. One person in care did not have a record of immunization.
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 persons admitted comply with the Province's immunization and tuberculosis control programs. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 26, 2021
Observations: Licensing audited three persons in care's charts. One person in care did not have a record of TB test.
3070 - RCR 81(3)(c)(ii)
Description: A care plan must include all of the following: a nutrition plan that specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets
Corrective Actions Required: Ensure that a care plan includes a nutrition plan that specifies the nutrition to be provided to the person in care. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 26, 2021
Observations: Licensing audited three persons in care's care plans. One care plan did not include a nutrition plan.
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 a person in care who is assessed to be a risk of falling has a fall prevention plan that includes a plan for following up on any falls suffered. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 26, 2021
Observations: Licensing audited three persons in care's care plans. One person in care who was assessed to be at risk of falls did not have a fall prevention plan which included a plan for following up on any falls suffered.