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)
Follow-Up
May 10, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 37(1)(a)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: a criminal record check for the person
Corrective Actions Required: Ensure staff have updated criminal record checks on file.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 22, 2024
Observations: Licensing reviewed twelve staff files and one staff file did not have a updated criminal record check.
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 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: March 22, 2024
Observations: Licensing observed the medication administration sheets for medication creams for March 2024 for ten persons in care and all ten persons in care did not have any staff signed for administration of medication creams. The Director of Wellness stated staff should be signing the medication administration sheets for administration of medication creams.
Licensing also observed missed staff signature for March 18, 2024, 1700hour medications for one person in care on the medication administration sheet.
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:
Corrective Actions Taken By Licensee: Licensing observed updated policies for 2024.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - CCALA 7(1)(b)(i)
Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing reviewed three person in care's bath records for April 2024 and all three persons in care bath records were documented as completed.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: