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
July 18, 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 person in care do not have access to water greater than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 18, 2022
Observations: Licensing tested the hot water in two sinks where person in care had access to hot water and the temperature was 51 and 52.3 degrees Celsius. This is an immediate risk to the health and safety of person in care. The Manager stated they will contact the maintenance supervisor covering to assess and will turn down the hot water today and that an audit of hot water will be conducted on two rooms per day on each floor on the next week.
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: Ensure all rooms and common areas are maintained and in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 1, 2022
Observations: Licensing toured the facility and observed a broken light fixture in a person in care's room, damage to baseboard strips in two person in care's room, and the hot water not working in a person in care's bathroom.
3010 - RCR 44(2)(a)
Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,
Corrective Actions Required: Ensure a Licensee who accommodates 50 or more person in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 18, 2022
Observations: The Facility has applied for an exemption to this section on July 15, 2022. Currently, there is no Food Service Manager employed with membership with the Canadian Society of Nutrition Management.
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 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: July 18, 2022
Observations: Licensing toured the facility and observed three medication cups with pre-poured medications on top of the first floor medication cart in the locked medication room. Licensing observed the narcotic record counts and noted multiple second staff signatures missing in the fourth floor nursing station. Licensing audited the Medication Administration Record and one person in care had not had four medications signed or coded on July 14, 2022.
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 each person in care has, in writing, consent 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 1, 2022
Observations: Licensing audited eight person in care's charts. Three person's in care did not have a record of written consent to call a medical or nurse practitioner or ambulance.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure care plans for all person's in care include a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 25, 2022
Observations: Licensing audited eight care plan's. Four person in care were missing 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: Ensure that if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, there is a plan to locate the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 25, 2022
Observations: Licensing audited eight care plan's. One person in care, who was at risk for elopement, did not have a plan to locate the person in care if they were missing.