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
March 15, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3020 - RCR 85(1)(d)
Description: A licensee must do all of the following: ensure that policies are implemented by employees.
Corrective Actions Required: Ensure policy implementation by employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2022
Observations: Licensing audited four staff files. Two staff files did not have a performance review in respect of the employees, who had been employed at the facility for over one year. Facility's policy required performance review once per year.
3030 - RCR 83(5)(a)
Description: If a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed
Corrective Actions Required: If a person in care refuses or is unable to be weighed, the licensee must record the reason why.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 15, 2022
Observations: Licensing audited two person in care's weight records. One person in care did not have weights documented for August, September, October and December 2021. The Manager indicated the person in care regularly refused being weighed.
3070 - RCR 81(3)(f)(i)
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 to prevent the person in care from leaving
Corrective Actions Required: Ensure that a care plan includes plans for preventing a person in care from leaving a facility without notifying employees, if at risk.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2022
Observations: Licensing audited two person in care's care plans. One person in care, at risk of leaving the facility without notifying an employee, did not have a plan for preventing the person in care from leaving the facility without notifying employees.
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 a care plan includes plans for locating a person in care who have left a facility without notifying employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2022
Observations: Licensing audited two person in care's care plans. One person in care, at risk of leaving the facility without notifying an employee, did not have a plan for locating the person in care.
3080 - RCR 72(a)
Description: A licensee must ensure that a person in care’s medication is returned to the dispensing pharmacy the person in care is no longer taking the medication
Corrective Actions Required: Ensure that medications are returned to the dispensing pharmacy if the person in care is no longer taking them.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 15, 2022
Observations: Licensing audited two person in care's medications. One person in care had four medications prescribed by a previous pharmacy which they were no longer taking, that had not been returned to the dispensing pharmacy.