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)
Non-Visit Follow-up
September 6, 2022
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: September 13, 2022
Observations: Licensing toured the facility and noted scrapes and gouges out of the wall in the dining room area on the sixth and fourth floors and to a person in care's wall in their room on the sixth floor.
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 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, 2022
Observations: Licensing audited the Narcotic record count binder on three floors. Multiple Narcotic counts had not been co-signed by staff and August 2, 5 and 7, 2022 did not have Narcotic counts completed by staff.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee: On August 30, 2022, Licensing received an email from the Director of Care which included two records of immunization status and two TB screens for persons in care.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 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, 2022
Observations: Licensing toured the facility and observed a medicated cream on the shelving beside the nursing station with no staff within the vicinity.
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 each 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: August 30, 2022
Observations: Licensing audited three medication rooms and three medication carts. One medication had expired in October 2021.