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
July 22, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 30(b)
Description: A licensee must ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower,
Corrective Actions Required: Ensure that all bathrooms have slip resistant material on the bottom of each bathtub and shower.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing observed one tub used by a person in care did not have a non slip surface.
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: August 21, 2022
Observations: Licensing audited the Medication Administration Record for five dates in July 2022 and observed two dates for one person in care on July 12 and July 15 at 1400 were not coded or signed for. Licensing audited the medication cart and observed Tylenol for a person in care was not labeled by the pharmacy.
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 record of compliance with the Providence's Tuberculosis and Immunization Program is kept.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited four staff files, and observed one did not have a record of immunization or TB.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure there is clear and up to date records of immunization status kept for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited three person in care's records and observed one record did not include a record of immunization status.
3070 - RCR 78(3)(a)
Description: A licensee must have, and keep with each person in care’s record, consent in writing from the person in care or a parent or representative of the person in care to call a medical practitioner, nurse practitioner or ambulance in case of accident or illness,
Corrective Actions Required: Ensure there is a consent in writing from the person in care, or representative of the person in care to call a nurse practitioner, medical practitioner or ambulance in case of accident or illness.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited three person in care's records and observed one record did not include a consent to call a nurse practitioner, medical practitioner, or ambulance.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure a are plan includes a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited three care plan's and observed one care plan did not include a recreation and leisure plan.
3070 - RCR 81(3)(f)(ii)
Description: A care plan must include all of the following:if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, a plan if the person in care leaves without notification, to locate the person in care
Corrective Actions Required: Ensure a care plan includes a plan for locating the person in care, if they are determined to be at risk of leaving the facility without notifying an employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited three care plan's and observed one care plan did not include a plan for locating a person in care if they left the facility without notifying an employee.
3070 - RCR 86(b)
Description: A licensee must keep the following records in respect of each employee: character references,
Corrective Actions Required: Ensure character references are kept in respect of each employee.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 21, 2022
Observations: Licensing audited four staff files, and observed one did not have a record kept of character references, in respect of the employee.