Island Health
1952 Bay Street Victoria, B.C. V8R 1J8 | Visit Official Website (opens in a new tab)

Douglas Care Community

Facility Type: Residential Care - 400

Follow-Up

June 12, 2024
Score & Grade: 0 Grade:
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.
Code
Category/Description
3010 - RCR 40(1)(b)
Description: A licensee must ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer under subsection (2) to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing audited six employee files. All employee files had a performance review dated within the last year.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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:
Corrective Actions Taken By Licensee: Licensing audited the electronic Medication Administration Record (eMAR) for the month of June 2024. All persons in care's medications were signed or coded for by staff as per the medication safety and advisory committee policies.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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: August 13, 2024
Observations: Licensing audited four person in care's weight records. All four persons in care had at least one monthly weight missing.