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
January 4, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - CCALA 7(1)(b)(i)
Description: A licensee must operate the community care facility in a manner that will promote the health, safety and dignity of persons in care
Corrective Actions Required: Ensure that that all cleaning agents and chemicals are safely and securely stored, and that the community care facility is operated in a manner that will promote 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: January 4, 2024
Observations: Licensing toured the facility on this date. Licensing found a cleaning agent in a person in care's bedroom and a utility room with cleaning agents inside unlocked. The Manager stated the cleaning agents would be locked away accordingly on today's date.
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 in the community care facility 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 4, 2024
Observations: Licensing toured the facility on this date. Licensing found two medicated creams with drug identification numbers in person in cares rooms not safely and securely stored. The Manager stated the medications would be removed from the rooms 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 and advisory committee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 11, 2024
Observations: Licensing reviewed the electronic medication administration record. On January 2, 2024, medications for the evening shift on second floor for all persons in care were not signed for by staff. In addition, on January 1, 2024, there was one medication on the day shift for a person in care not signed for by staff.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure clear and up to date records of immunization status are kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 4, 2024
Observations: Licensing audited seven person in care's files. Two persons in care were missing a record of immunization status.
3060 - RCR 49(1)
Description: A licensee must require all persons admitted to a community care facility to comply with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure all persons in care admitted to a community care facility to comply with the Province's immunization tuberculosis and control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 4, 2024
Observations: Licensing audited seven person in care's files. Two persons in care did not have a record of tuberculosis screening.
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 each person in care has, in writing, consent from the person in care or a parent or representative of the person in care, consent to call a medical practitioner, nurse practitioner, or ambulance, in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 4, 2024
Observations: Licensing audited seven person in care's charts. All seven persons in care did not have a record of written consent to call a medical or nurse practitioner or ambulance.
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 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: January 11, 2024
Observations: Licensing audited seven person in care's care plans. Two persons in care, who were at risk for elopement, did not have a plan to locate the person in care if they were missing.
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: April 4, 2024
Observations: Licensing audited seven person in care's weight records. Five persons in care had multiple weights missing for the previous 6 months.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that all employee files have a record of character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 4, 2024
Observations: Licensing audited eleven employee files. Three employee files had only one character reference.