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 12, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - 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 the facility is operated in a manner that promotes the health, safety and dignity of persons in care. Specifically, that cleaning agents, chemical products and other hazardous materials 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 12, 2024
Observations: Licensing toured the facility and observed cleaning products that were not safely or securely stored.
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 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 12, 2024
Observations: Licensing toured the facility and observed five medications in a bedroom of a person in care that were not safely or securely stored.
3010 - RCR 43(1)(a)
Description: A licensee must ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate, provided on completion of a course that meets the requirements of Schedule C,
Corrective Actions Required: Ensure that persons in care have at all times immediate access to an employee who holds a valid first aid and CPR certificate.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: January 15, 2025
Observations: Licensing audited the staff files and one staff who worked alone with persons in care, did not have any First Aid or CPR certificate on file.
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: December 13, 2024
Observations: Licensing audited the Medication Administration Records (MARs) of four persons in care. Staff had not signed for or coded the MAR on four dates in November 2024.
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: February 13, 2025
Observations: Licensing audited the weight records of persons in care and one person in care had not been weighed since April 2024.
3080 - RCR 69(1)(a)
Description: A licensee must ensure that a pharmacist packages all medications
Corrective Actions Required: Ensure that a pharmacist packages all medications.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 13, 2024
Observations: Licensing toured the facility and observed five medications that were not labelled by the pharmacy in a bedroom of one person in care. Licensing audited the medication storage area and observed two medications not labelled by the pharmacy.
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 medications are 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: November 12, 2024
Observations: Licensing toured the facility and observed two expired medications in the bedroom of one person in care.