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 16, 2023
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing toured the seventh floor and observed no marks or scrapes on the walls in the rooms of persons in care or in the common areas.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited performance reviews and all staff audited had performance reviews in the past year.
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: Ensure that all employees comply with 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 30, 2023
Observations: Licensing audited the Narcotic record count binder on three floors. Multiple dates in March 2023 did not have Narcotic counts completed and signed by staff. Licensing audited the Narcotics record count binder on three floors. May 12 and 13, 2023 did not have Narcotic counts completed and signed by staff.
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 policies that were last reviewed in April 2023.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing toured the facility and observed all medications safely and securely stored.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited three medication rooms and three medication carts and did not observe any expired medications.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: