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)
Follow-Up
August 1, 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: August 30, 2024
Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing inspected the rooms of persons in care. Several medicated creams were located in unlocked cabinets in the several rooms of persons in care.
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: August 30, 2024
Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing audited the Medication Administration Records of persons in care. PRN medications were documented as administered without the result of the PRN effectiveness documented regularly and consistently.
3030 - RCR 81(1)
Description: If a person in care is admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care is made in accordance with this section within 30 days of admission.
Corrective Actions Required: Ensure if a person in care was admitted to the community care facility for a period of more than 30 days, a licensee must ensure that a care plan for the person in care was made in accordance with this section within 30 days of admission.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 30, 2024
Observations: Licensing audited eight care plans, five LTC care plans and three Hospice care plans, and two of the Hospice care plan only contained a short term care plan when the persons in care resided at the facility more than 30 days. One of the care plan was dated April 2023 and May 2024.
3070 - CCALA 7(1)(b)(i)
Description: A licensee must do all of the following: (b) operate the community care facility in a manner that will promote (i) the health, safety and dignity of persons in care,
Corrective Actions Required: Ensure to operate the communicate care facility in a manner that would 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: August 30, 2024
Observations: Licensing audited eight persons in care's care plan, and observed written care information written in pencil that was being erased.
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 a month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 30, 2024
Observations: This item has been carried forward from Routine Inspection dated July 5, 2023. On this date, Licensing reviewed the weight records for persons in care. Many records were missing 1-4 months where weights were not recorded for persons in care.