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
February 16, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - RCR 43(2)
Description: A licensee must have first aid supplies that are readily accessible to all employees, including while care is provided off the community care facility premises.
Corrective Actions Required: Ensure first aid supplies are readily accessible to all employees.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 17, 2022
Observations: Licensing observed the first aid supplies in the locked staff room.
3020 - RCR 68(3)(b)(i)
Description: The medication safety and advisory committee must establish and review as required policies and procedures in respect of the safe and effective storage, handling and administration of the person in care’s medications, in compliance with the Pharmacists, Pharmacy Operations and Drug Scheduling Act
Corrective Actions Required: Ensure MSAC policies regard administration of medication are implemented by staff.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 17, 2022
Observations: Licensing observed one person in care's PRN were not signed for result follow up as per the medication policy.
3070 - RCR 77(2)(c)
Description: Subject to subsection (3), if a person in care is involved in a reportable incident, the licensee must immediately notify a medical health officer, in the form and in the manner required by the medical health officer
Corrective Actions Required: Ensure MHO is notified immediately when person in care involved in a reportable incident.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 17, 2022
Observations: Licensing observed two reportable incident on staff file that were not reported to Licensing.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 17, 2022
Observations: Licensing observed Shopper Pharmacy labels of three persons in care's multiple medications. Shopper is not the supervising pharmacy and Richmond Medical Pharmacy is the supervising pharmacy.
3090 - RCR 55(1)(a)(i)
Description: A licensee, other than a licensee who provides a type of care described as Hospice, must provide persons in care, without charge, with an ongoing planned program of physical, social and recreational activities suitable to the needs of the persons in care
Corrective Actions Required: Ensure there is on ongoing plan program of recreation suitable to needs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 17, 2022
Observations: Licensing observed on ongoing plan program of recreation for persons in care. Manager stated they did not have a written ongoing plan.