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
October 30, 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 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 30, 2024
Observations: Licensing toured 17 persons in care's rooms. In three rooms there were topical creams that were not safely and securely stored.
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 employees comply with the policies 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: November 30, 2024
Observations: Licensing audited the narcotic counts in four medication rooms. All four medication rooms had narcotics that were not signed by two staff and were not completed on multiple shifts. Licensing confirmed that narcotic counts were to be completed on each shift and signed by two nurses.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure that policies are reviewed and if necessary revised, at least once per year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By: November 30, 2024
Observations: Licensing audited the policies and procedures for the facility. Three policies had not been reviewed or revised since 2022.
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required: Ensure that if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, there is a plan if the person in care leaves without notification, to locate the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 30, 2024
Observations: Licensing audited 16 persons in care's care plans. Four persons in care were assessed to be high risk to elope from the facility. All four care plans did not have a plan regarding how to locate the person in care, in the event they went missing.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 30, 2024
Observations: Licensing audited four medication rooms. In two medication rooms there were unlabelled medications.
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 pharmacy when expired.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 30, 2024
Observations: Licensing audited four medication rooms. In one medication room there were expired contingency medications and in one medication room there were expired narcotics.