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
March 26, 2024
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:
Corrective Actions Taken By Licensee: Licensing audited the sinks in five persons in care's bathroom and temperature measured under 49 degrees Celsius in all five.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 that all rooms and common areas are maintained in good state of repair
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing toured 5 bedrooms of persons in care and observed wall damage in two bedrooms.
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: April 19, 2024
Observations: Licensing audited the medication cupboards and observed one narcotic that did not have an expiry date. Licensing audited the medication administration records and on four dates in March 2024, there was no signature or coding for one medication for one person in care by staff.
3010 - 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.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited 11 staff files and observed two staff files only had one character reference included.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure all care plans include an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited the care plans of five persons in care. Three persons in care did not have a care plan that addressed oral health care.
3070 - RCR 81(3)(c)(ii)
Description: A care plan must include all of the following: a nutrition plan that specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets
Corrective Actions Required: Ensure all care plans include a nutrition plan plan that specifies the nutrition to be provided to the person in care, including the requirements of any therapeutic diets.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited the care plans of six persons in care. Three person in care's care plans were missing a nutrition plan.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure all care plans 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: April 19, 2024
Observations: Licensing audited the care plans of six persons in care. Two persons in care's care plans did not address recreation and leisure.
3070 - RCR 81(3)(e)(i)
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 an assessment of the nature of the risk of falling presented by the person in care
Corrective Actions Required: Ensure all care plans include a fall prevention plan which addresses an assessment of the nature of the risk of falling presented by the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited the care plans for six persons in care. Two persons in care, who were at risk for falls, did not have a fall prevention plan addressing the assessment of risk of falling.
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 all care plans include a fall prevention plan which must address a plan for preventing the person in care from falling
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited the care plans of six persons in care. Three person in care's care plans did not have a fall prevention plan.
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 all care plans include a fall prevention plan which must address a plan for following up on any falls suffered by a person in care .
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 19, 2024
Observations: Licensing audited the care plans of six persons in care. Three persons in care did not have a fall prevention plan.
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 toured the facility and audited the medication cupboards and observed no expired medication.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: