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 18, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 22(1)(b)
Description: A licensee must ensure that all rooms and common areas are maintained in a good state of repair
Corrective Actions Required: Ensure that all rooms and common areas are maintained in a good state of repair.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: Licensing toured the facility and observed wall damage in a bedroom of a person in care, as well as an exposed wire in the bedroom of a person in care.
3010 - RCR 40(1)(a)
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 continues to meet the requirements of this regulation,
Corrective Actions Required: Ensure that the performance of each employee is reviewed regularly as directed by the medical health officer under subsection (2) to ensure that the employee continues to meet the requirements of this regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: This contravention was carried over from the Routine Inspection dated September 25, 2023. On this date, Licensing was made aware that one performance review for a staff remained outstanding.
3010 - RCR 86(a)
Description: A licensee must keep the following records in respect of each employee: criminal record check results,
Corrective Actions Required: Ensure that criminal record check results are kept for each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: Licensing audited six staff files and observed that one staff did not have criminal record check results kept on-file.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that clear and up to date records of immunization status are kept for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: Licensing audited the charts and care plans for three persons in care, and did not observe a record of immunization kept on-file for two persons in care.
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 that for each person in care, there is a record showing 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: April 18, 2024
Observations: Licensing audited the charts and care plans for three persons in care and observed that two persons in care did not have a record of consent to call a medical practitioner, nurse practitioner, or ambulance in case of accident or illness.
3080 - 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: March 18, 2024
Observations: Licensing toured the facility and observed a medication that was not safely or securely stored.
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 dispensing pharmacy if the expiry date on the medication has passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: March 18, 2024
Observations: Licensing audited the medication room and tub room medication rooms, and observed three expired medications.