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
January 20, 2022
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 in the facility are safety securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2022
Observations: This item has been carried over from Follow Up Inspection JMCL-C7ANDK dated September 28, 2021. Licensing toured the facility on this date. Licensing observed medications in five person in care's rooms that were not safely securely stored, and two care carts unsupervised with accessible medications.
3010 - RCR 40(1)(a)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer to ensure that the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2022
Observations: This item has been carried over from Routine Inspection JMCL-C56LRJ dated July 22, 2021. Licensing audited 30 employee files. Seven files did not have a performance review that was regularly reviewed.
3010 - RCR 40(1)(b)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer to ensure the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2022
Observations: This item has been carried over from Routine Inspection JMCL-C56LRJ dated July 22, 2021. Licensing audited 30 employee files. Seven files did not have a performance review that was regularly reviewed.
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: Ensure all policies and procedures are reviewed at least once each year/revised as necessary.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 20, 2022
Observations: Licensing audited the facility policies and procedures. Four policies were last reviewed in August 2020 and one policy was last reviewed in February 2019.
3070 - RCR 77(2)(c)
Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Corrective Actions Required: Ensure the Medical Health Officer is notified immediately when persons in care are involved in a reportable incident.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2022
Observations: Licensing audited an employee file, and observed staff disciplinary letters which indicated persons in care were subjected to emotional abuse. This had not been reported to Licensing.
3070 - RCR 81(3)(e)(ii)
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 preventing the person in care from falling
Corrective Actions Required: Ensure that there are fall prevention plans addressing prevention from falling included in care plan for those prone to falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 3, 2022
Observations: Licensing audited 26 person in care's care plans. One person in care who was at risk for falling did not have a plan to prevent falls.
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 there are fall prevention plan addressing follow-up to falls suffered included in care plan for those prone to falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 3, 2022
Observations: Licensing audited 26 person in care's care plans. Four persons in care who were at risk for falling did not have a plan to follow up on falls suffered.
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 that a person in care's medication is returned to the dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 20, 2022
Observations: This item has been carried over from Routine Inspection JMCL-C56LRJ dated July 22, 2021. Licensing audited the medication carts and rooms on two floors. Licensing observed five expired medications in a medication room. The expiry dates ranged from September to December 2021. Nursing staff were informed of the expired medications.