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
March 14, 2024
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: Ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 2, 2024
Observations: Licensing observed the tub rooms on the first and second floor. Both bathtubs did not have slip resistant material on the bottom of the bathtub. The Licensee has submitted an exemption request for this section of legislation which is in process with the Licensing program.
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 that if there are 50 or more persons in a community care facility, that the food services manager is a nutrition manager with 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: April 14, 2024
Observations: The Licensee has submitted an exemption to this section of legislation which is in process with the Licensing program.
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 staff comply with the policies and procedures of the medication safety advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 14, 2024
Observations: Licensing audited the medication administration record and observed one medication for a person in care that was not signed for or coded by staff on March 4, 2024. Licensing audited the Narcotic Count records and observed that on five occasions, a second staff signature was missing as required by policy.
3030 - RCR 63(3)(c)(iii)
Description: A licensee must ensure that meals are provided by ongoing room tray service, if approved by the person in care’s medical practitioner or nurse practitioner
Corrective Actions Required: Ensure that approval is obtained form the medical/nurse practitioner if a person in care receives ongoing tray service.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 2, 2024
Observations: Licensing audited 15 person in care's records. Two persons in care who received ongoing tray service did not have approval from the medical/nurse practitioner on file.
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure that the consent for a person in care to be admitted is obtained given in accordance with Section 21 and 22 of the Health Care (Consent) and Care Facility (Admission) Act or Section 50.1 of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 14, 2024
Observations: Licensing audited 15 person in care's records. One person in care did not have a record of consent to be admitted to the facility.
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 that all persons in care have written consent to call a medical/nurse practitioner or ambulance in the case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 14, 2024
Observations: Licensing audited 15 person in care's records. Two persons in care did not have written consent to call a medical/nurse practitioner or ambulance in the case of accident or illness.
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 that if a person in care has been determined to be at risk for falling, that they have a fall prevention plan that includes a plan that addresses an assessment of the nature of risk for falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 21, 2024
Observations: Licensing audited 15 person in care's care plans. One person in care who was determined to be at risk for falls, did not have a fall prevention plan that addressed an assessment of the nature of risk for falling.
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 that if a person in care has been determined to be at risk for falls, that they have a fall prevention plan that includes a plan to follow up on any falls suffered by the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 21, 2024
Observations: Licensing audited 15 person in care's care plans. One person in care who was determined to be at risk for falls, did not have a plan to follow up on any falls suffered by the person in care.
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 if a person in care's medication has expired that it is returned to the dispensing pharmacy.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 14, 2024
Observations: Licensing audited four medication carts and two medication rooms on this date. Licensing observed one medication that had expired in January 2024 located in a medication cart.