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
March 25, 2025
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:
Corrective Actions Taken By Licensee: Licensing audited the electronic Medication Administration Record (eMAR) and observed that all medication had been signed and coded for by staff between March 17 and 23, 2025, as per policy.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that criminal record check results are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 17, 2025
Observations: Licensing audited six staff files and observed that one staff had a criminal record check that expired in June 2024, and did not have an up to date criminal record check kept on-file.
3030 - 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:
Corrective Actions Taken By Licensee: Licensing toured the bedroom of a person in care, and observed that signage that indicated the person in care was not to have any items in their bathroom, including lotions, soap, or hand sanitizer, had been removed and was addressed in the care plan, and that items were not accessible or within reach of the person in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure that for each person in care, there is a record showing consent, in writing, from the person in care or a parent or representative of the person in care, to call a medical practitioner, nurse practitioner, or ambulance in the case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 17, 2025
Observations: Licensing audited four person in care's records and charts, and observed that four did not have a record of consent to call a medical practitioner, nurse practitioner, or ambulance in case of accident or illness.
3070 - RCR 80(1)
Description: On admitting a person in care to a community care facility, a licensee must ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care
Corrective Actions Required: Ensure that a short term care plan is developed that will guide caregivers in protecting and promoting the health and safety of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2025
Observations: Licensing audited four care plans and observed that two care plans, for persons in care who were both admitted in March 2025, were missing multiple required sections of a short term care plan.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure that a care plan includes an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 17, 2025
Observations: Licensing audited four care plans for persons in care and observed that one care plan did not include an oral health care 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 that a care plan addresses a plan for 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: March 24, 2025
Observations: Licensing audited four care plans for persons in care and observed that one care plan did not include a plan for following up on any falls suffered by the person in care.
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 to be at risk of leaving the community care facility without notification of an employee, that the care plan contains a plan to located the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 24, 2025
Observations: Licensing audited four care plans for persons in care and observed that one person in care who had been determined to be at risk of leaving the community care facility without notification of an employee, was missing a plan to locate the person in care.