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
November 27, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 69(3)(a)
Description: A licensee must ensure that all medications in the community care facility are safely and securely stored,
Corrective Actions Required: Ensure that all medications are safely and securely stored.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 27, 2024
Observations: Licensing toured the facility on this date. One person in care's bedroom had two medicated creams that were not safely or securely stored. The Director of Care indicated the creams would be secured on today's date.
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 advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 11, 2024
Observations: Licensing audited the electronic Medication Administration Record for persons in care dated between November 20 to 27, 2024. On November 26, 2024, there was one person in care who did not have medications signed as administered for their 2000hr medications. The Medication Safety Advisory Committee policies indicate signing for medications once administered by staff.
3070 - CCALA 7(1)(b)(i)
Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Corrective Actions Required: Ensure that the community care facility is operated in a manner that promotes the health, safety and dignity of persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 27, 2024
Observations: Licensing audited eight person in care's care plans. Four person in care's care plans indicated a use of restraint that required monitoring to be signed off by staff. Two persons in care's restraint monitoring records were missing staff signatures for multiple dates in November 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 if 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: November 27, 2024
Observations: Licensing audited two medication carts. In one medication cart Licensing observed two expired narcotic medications dated October 2024.