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
December 12, 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: Ensure the water accessible to a person in care, from any source, is not heated more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2024
Observations: Licensing toured the facility on this date and checked the hot water temperature in person in care's rooms on three separate floors. In seven person in care's bedrooms, there was hot water ranging from 50 and 65 degrees Celsius. This represents an immediate risk to the health and safety of persons in care and must be corrected immediately. On this date, the Manager informed the maintenance department to assess the hot water temperature, at varying times each day, to ensure the temperature remains under 49 degrees Celsius. Full compliance will not be achieved until the plan has been implemented and completed.
3000 - RCR 21(c)
Description: A licensee must ensure that all furniture and equipment for use by persons in care are maintained in a good state of repair,
Corrective Actions Required: Ensure that all furniture and equipment for use by persons in care are maintained 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: January 12, 2025
Observations: Licensing toured the facility on this date. In two person in care's bedrooms there was a dresser that had a missing handle.
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 (MSAC).
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2024
Observations: Licensing audited the electronic Medication Administration Record (eMAR). On December 4 and 8, 2024, there were multiple persons in care that did not have medications signed for or coded by staff on one unit as per the Medication Safety and Advisory Committee (MSAC) policies.
3070 - RCR 83(4)(a)
Description: Subject to subsection (5), a licensee, other than a licensee who provides a type of care described as Hospice, must ensure that each person in care is weighed at least once each month,
Corrective Actions Required: Ensure that each person in care is weighed at least once each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 12, 2025
Observations: Licensing audited 19 person in care's weight records for the last six months. Three persons in care had a missing monthly weight in July 2024.
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: 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 12, 2024
Observations: Licensing audited three medication carts and rooms. There was nine expired medications between all three units dated between May and November 2024.