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 7, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure that policies are implemented by employees, including medication policies.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 6, 2023
Observations: Licensing audited the facility's medications and observed one person in care's Lorazepam that was not labelled, in the medication fridge that had been dispensed on November 26, 2022. The Director of Care stated the medication should have been labelled or disposed of.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that each person in care's records includes a clear and up to date record of immunization history.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 6, 2023
Observations: Licensing audited six person in care's records and observed three persons in care's records did not include a record of immunization history.
3070 - RCR 77.1(1)(c)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: each assessment report, if any, provided under section 22 (1) (c) of the Health Care Consent Regulation.
Corrective Actions Required: Ensure assessments are kept, in respect of each person in care's consent to admission records, if required.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 6, 2023
Observations: Licensing audited three person in care's records regarding consent to admission. Three person in care's consent to admission did not include incapability assessments as required.
3070 - RCR 81(4)(b)(i)
Description: A licensee must ensure that each care plan is reviewed and, if necessary, modified if there is a substantial change in the circumstances of the person in care
Corrective Actions Required: Ensure that each care plan is reviewed and modified if there is a substantial change in the circumstances of the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 6, 2023
Observations: Licensing audited six person in care's care plans. One person in care was identified as an elopement risk. The Director of Care stated the person in care was no longer an elopement risk.