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 5, 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: January 6, 2025
Observations: Licensing observed medication caddy's of topical medication that were accessible to persons in care outside the medication room doors. Additionally, Licensing observed four bedrooms with multiple topical medications that were not safely or securely stored.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure that each care plan includes a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 5, 2025
Observations: Licensing audited eleven care plans of persons in care and three did not contain a recreation and leisure plan.
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 care plans include a fall prevention plan that addresses a plan for following up on any falls suffered by a person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 5, 2025
Observations: Licensing audited eleven care plans for persons in care and ten did not include a fall prevention plan that addressed a plan for following up on any falls suffered by a person in care.
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: March 5, 2025
Observations: Licensing audited eleven care plans of persons in care and two persons in care, who were at risk for going missing, did not have a plan to locate the person in care if they left without notification.
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: March 5, 2025
Observations: Licensing audited eleven records of persons in care and four persons in care did not have a record of weights recorded monthly.
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: January 6, 2025
Observations: Licensing observed two medications in a medication room and multiple medications in four bedrooms that were not packaged and labelled by the pharmacy.