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
August 9, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing observed one tub used by a person in care had a non slip surface.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 21, 2022
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 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: September 9, 2022
Observations: Licensing audited the Medication Administration Record for five dates in July 2022 and observed two dates for one person in care on July 12 and July 15 at 1400 were not coded or signed for. Licensing audited the medication cart and observed Tylenol for a person in care was not labeled by the pharmacy.
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited one staff files, and observed one had a record of TB.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 21, 2022
Observations:
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure there is clear and up to date records of immunization status kept for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 9, 2022
Observations: Licensing audited one person in care's records and observed they did not include a record of immunization status. The Manager stated they were waiting for documentation from the person in care's physician.
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:
Corrective Actions Taken By Licensee: Licensing audited one person in care's record, and observed they had a written consent to call a nurse practitioner, medical practitioner, or ambulance.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: Licensing
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:
Corrective Actions Taken By Licensee: Licensing audited one person in care's records and observed it included a consent to call a nurse practitioner, medical practitioner, or ambulance.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 21, 2022
Observations:
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited three person in care's care plans, and observed they all included a recreation and leisure plan.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 21, 2022
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited one care plan, and observed it includes a plan for locating the person in care if they left the facility without notifying an employee.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: August 21, 2022
Observations:
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure character references are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: September 9, 2022
Observations: Licensing audited one staff file, and observed it did not have a record kept of character references, in respect of the employee.