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
October 7, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that hot water acessible to person in care does not exceed 49 degrees celcius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 15, 2022
Observations: Licensing tested seven sinks accessible to persons in care and the temperatures were 52.8, 50.2, 52, 51, 49.9, 51.9, 51.6. This represents a immediate risk to the health and safety of the persons in care and must be corrected immediately. A plan for corrective action was submitted by the maintenance manager on September 15, 2022 that stated a review of the hot water valves will occur immediately to turn down the hot water temperature. The facility will conduct daily audits of the hot water until full compliance is achieved and maintained.
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required: Ensure that all bathrooms have slip resistant material on the bottom of the bathtub or shower.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing toured the facility and the second floor tub room did not have slip resistant material on bottom of bathtub or a slip resistant mat.
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 in the community care facility are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing toured the facility and audited seven person in care bedroom. On the second floor barrier creams were found in the bathroom of three person in care and a medicated zinc oxide cream found in one person in care bathroom.
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 a criminal record check is obtained for all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited eleven employee files. One employee file did not have a criminal record check.
3010 - RCR 37(1)(b)
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: character references in respect of the person
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed two employee files that did not have reference checks and both files had records of reference checks.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Ensure that all employees comply with the policies and procedures of Medication Safety & Advisory Committee.
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited six person in care's Medication Administration Records. One person in care's Medication Administration Record was missing signatures for September 9, 2022 for medications scheduled to be administered at 8:00am.
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:
Corrective Actions Taken By Licensee: Licensing observed the files of two employees missing TB records and both files had records of TB.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 Provinces immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited six person's in care charts. One person in care did not have a record of tuberculosis testing.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure a care plan includes a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing audited six person's in care care plans. One person in care did not have a recreation and leisure plan.
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:
Corrective Actions Taken By Licensee: Licensing audited the person in care who was at risk for elopement chart and observed a plan to locate if the person in care eloped.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: September 29, 2022
Observations:
3080 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure that the community care facility is operated in a manner that will promote the health, safety, and dignity of all persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 29, 2022
Observations: Licensing toured the facility. On the second floor the cupboard near the dining room containing cleaning agents and disinfectants was unlocked and accessible to person in care. One the second floor tub room cleaning agents and disinfectants were left beside the tub and on a shelf.