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
November 4, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required: Ensure that the water accessible to a person in care, from any source, is not heated to more than 49 degrees Celsius.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 5, 2021
Observations: Licensing observed multiple persons in care bathroom sinks on three floors with water heated to 51.1, 53.7, 53.1, 51.7 and 53.1 degrees Celsius. A plan for corrective action is to be submitted to Licensing by November 4, 2021. Full compliance will not be achieved until the plan has been implemented and completed.
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: December 6, 2021
Observations: Licensing observed on two floors worn, scuffed lounged walls with paint missing. Licensing observed one person in care's bedroom has worn scuffed walls.
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: November 5, 2021
Observations: Licensing observed one medication left in view in three separate persons in care's bedrooms.
3010 - RCR 37(1)(e)
Description: A licensee must not employ a person in a community care facility unless the licensee or, in the case of a person who is not the manager, the manager has obtained all of the following: evidence that the person has complied with the Province’s immunization and tuberculosis control programs.
Corrective Actions Required: Ensure that staff have evidence that complies with the Province's immunization and tuberculosis control program.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: This item has been carried forward from the Routine Inspection JPAK-BUKZ2 dated October 8, 2020. Licensing reviewed forty staff files and observed nineteen staff files did not have compliance with the Province's immunization and tuberculosis control programs.
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: November 19, 2021
Observations: Licensing observed that the nurse did not administer the Insulin medication for person in care as per the pharmacy order stated it be administered prior to breakfast.The person in care had breakfast and had to wait until 9:30 am for the Insulin medication. The nurse stated she got distracted.
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 each employee has a record of criminal record check results.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 21, 2021
Observations: This item has been carried forward from the Routine Inspection JPAK-BUKZ2 dated October 8, 2020.Licensing observed that criminal record checks were missing for staff files.
3020 - RCR 74(1)(b)(i)
Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the person in care, the parent or representative of the person in care or the relative who is closest to and actively involved in the life of the person in care,
Corrective Actions Required: Ensure the written agreement to the use of a restraint for persons in care residing on the three locked units are signed by the representatives of the persons in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: This item has been carried forward from Routine Inspection JPAK-BU8KZ2 dated October 8, 2020. The Manager stated the written agreement from representatives to the use of a restraint for persons in care residing on the three locked units was not completed.
3020 - RCR 74(1)(b)(ii)
Description: Subject to subsection (2), a licensee may restrain a person in care if there is agreement to the use of a restraint given in writing by both the medical practitioner or nurse practitioner responsible for the health of the person in care.
Corrective Actions Required: Ensure the written agreement for persons in care residing on the three locked units are signed by the medical practitioner or nurse practitioner.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: This item has been carried forward from Routine Inspection JPAK-BU8KZ2 dated October 8, 2020. The Manager stated the written agreement signed by the medical practitioner or nurse practitioner for the persons in care residing on the three locked units were not completed.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure the policies and procedures are reviewed and revised if necessary at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: The Manager stated that last revision of policies and procedures occurred in May 2020. The Manager stated they had not received the May 2021 revision of policies and procedures.
3030 - 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 greeters are wearing eye protection during the screening for COVID-19 as per the Provincial Order.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 5, 2021
Observations: Licensing observed two greeters not wearing eye protections during the screening process for COVID-19 as per the Provincial Order.
3030 - RCR 63(3)(c)(iii)
Description: A licensee must ensure that meals are provided by ongoing room tray service, if approved by the person in care’s medical practitioner or nurse practitioner
Corrective Actions Required: Ensure that person in care's medical practitioner or nurse practitioner approves the meals that are provided by ongoing room tray service.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: Licensing reviewed six person in care's care plan where meals were provided by ongoing room tray service and one care plan did not have approval of the person in care's medical practitioner or nurse practitioner.
3060 - CCALA 7 (1)(b)(i)
Description: A Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care.
Corrective Actions Required: Ensure a Licensee must do all of the following: operate the community care facility in a manner that will promote the health, safety and dignity of persons in care, specifically that all dirty utility rooms are kept locked.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 5, 2021
Observations: Licensing observed the dirty utility rooms unlocked on two out of three floors. Staff stated to Licensing that the dirty utility rooms were to be kept locked.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure each person in care have clear and up to date records of immunization status.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 6, 2021
Observations: Licensing reviewed thirty persons in care's files and two persons in care's files did not have clear an up to date records of immunization status.
3070 - RCR 77.1(1)(b)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: in the case of an adult, the consent for that person in care to be admitted or to continue to be accommodated in the community care facility, given in accordance with section 21 or 22 of the Health Care (Consent) and Care Facility (Admission) Act or section 50.1 of this regulation, as applicable
Corrective Actions Required: Ensure a record of consent for person in care to be admitted or to continue to be accommodated in the community care facility in accordance with the Health Care (Consent) and Care Facility (Admission) Act.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations: Licensing reviewed thirty persons in care's files and observed two persons in care did not have a record of Health Care Consent.
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: December 6, 2021
Observations: Licensing reviewed eighteen weight charts for persons in care and observed eights weight charts had multiple missing weight entries over the last six months.
3070 - 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 each employee has a criminal record check result. Action/s Required by Licensing: Follow Up Inspection to be conducted.
Corrective Actions Taken By Licensee:
Actions Required By Licensing:
To Be Corrected By: November 19, 2021
Observations: Licensing reviewed forty staff files and nine staff files did not have criminal record check results.
3070 - RCR 93
Description: A licensee must, to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Corrective Actions Required: Ensure to the greatest extent possible while maintaining the health, safety and dignity of persons in care, keep the records and personal information of persons in care confidential.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: November 19, 2021
Observations: Licensing observed the nursing staff left the medication cart computer unlocked with person in care's personal information accessible to other in the hallway while the nurse went into a bedroom to administer medication.