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
January 9, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 62(4)
Description: A licensee who provides a type of care described as Long Term Care must display in a prominent place in each dining area the menu for each weekly period.
Corrective Actions Required: Ensure a menu for each week is displayed in a prominent place in each dining area.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing toured the facility and there was no menu displayed in the second floor dining room.
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 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing audited 11 staff files. Four staff files had no record of performance reviews conducted. Four staff files had performance reviews last conducted in 2019 or 2020.
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: January 16, 2024
Observations: Licensing audited the medication administration record. On January 6, 2024, one person in care's evening medications were not signed or coded for by staff. On January 4, 2024, two person in care's morning medications were not signed or coded for by staff. Licensing audited six person in care's bedrooms and observed multiple medications not labelled by the pharmacy in two person in care's bedrooms.
3010 - RCR 86(c)
Description: A licensee must keep the following records in respect of each employee: compliance with the Province’s immunization and tuberculosis control programs,
Corrective Actions Required: Ensure that for each employee a record is kept in compliance with the Provinces immunization and tuberculosis control programs.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing audited 11 staff files. Four staff files did not have a record of immunization. Three staff files did not have a record of Tuberculosis.
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 that for each person in care, a record is kept showing 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing audited six person in care's charts. Three person in care did not have a record of consent to admission.
3070 - RCR 81(3)(a)(iii)
Description: A care plan must include all of the following: a plan to address if there is agreement to the use of restraints under section 74 (1) (b) [when restraints may be used], the type or nature of restraint and the frequency of reassessment
Corrective Actions Required: Ensure that, if there is agreement to the use of restraints under Section 74(1)(b), a care plan includes the type or nature of a restraint and the frequency of reassessment.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing audited the care plan's of six person in care. Three person in care who lived in Memory Care, a secure unit, did not have the environmental restraint included in the care plan.
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 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: February 9, 2024
Observations: Licensing audited six person in care's charts and four charts were missing a record of weight for multiple months.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure that for each employee a record is kept of character references.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: February 9, 2024
Observations: Licensing audited 11 staff files. Three staff files did not have a record of character references.
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 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: January 9, 2024
Observations: Licensing audited six person in care's bedrooms. Three person in care's bathroom cabinets contained medications that were 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 expiry date on the medication had passed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 9, 2024
Observations: Licensing audited six person in care's bedrooms and observed one expired medication cream in one bedroom.