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
October 25, 2023
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 all employees are following 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: November 25, 2023
Observations: Licensing audited the Medication Administration Record of two persons in care. One person in care did not have 1600hrs medications signed or coded for by staff on October 2, 2023. One person in care did not have 0800hrs, 1200hrs, or 2000hrs medications signed or coded for by staff on October 1, 2023 and October 18, 2023. A medicated cream for a person in care was ordered by a Physician to be administered twice daily, and the Medication Administration Record indicated it was being signed as administered as a PRN or 'as needed' basis.
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 promotes the health, safety, and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: October 25, 2023
Observations: Licensing toured the facility and observed an equipment cleaner and Lysol bleach cleaner in a bathroom cupboard that was accessible to persons in care.
3080 - 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 that 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: October 25, 2023
Observations: Licensing toured the facility and observed two medicated creams in a bedroom of one person in care that were not safely or securely stored.
3090 - RCR 55(1)(a)(ii)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities designed to meet the objectives of the care plans of the persons in care,
Corrective Actions Required: Ensure persons in care are provided with an ongoing planned program of physical, social, and recreational activities that are suitable to the needs of the persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 25, 2023
Observations: Licensing audited the program of activities for two person in care and one person in care did not have a scheduled program of activities for 6 days of the week.