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 27, 2024
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: December 27, 2024
Observations: Licensing toured the facility and observed significant damage to the hallway on the second floor, east wing.
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 27, 2024
Observations: Licensing audited five person in care's Medication Administration Records (MARs). One person in care had one medication not signed and/or coded for by staff at 6:00 a.m. on November 19, 20 and 26, 2024. One person in care had one medication not signed and/or coded for by staff at 8:00 a.m. on November 5, 2024. One person in care had one medication not signed and/or coded for by staff at 6:00 a.m. on November 19, 2024.
3070 - RCR 77.1(1)(c)
Description: Subject to subsections (2) to (4), a licensee must keep, for each person in care, a record showing the following information: each assessment report, if any, provided under section 22 (1) (c) of the Health Care Consent Regulation.
Corrective Actions Required: Ensure that each person in care had records kept in relation to section 22(1)(c) of the Health Care Consent Regulation.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 27, 2024
Observations: Licensing audited six person in care's records. Two persons in care did not have incapability assessments as required under section 22(1)(c) of the Health Care Consent Regulation.
3070 - RCR 81(3)(b)
Description: A care plan must include all of the following: an oral health care plan
Corrective Actions Required: Ensure that a care plan includes an oral health care plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 27, 2024
Observations: Licensing audited six person in care's care plans and observed two care plans did not include an oral health care plan.
3070 - RCR 81(3)(d)
Description: A care plan must include all of the following: a recreation and leisure plan
Corrective Actions Required: Ensure that each person in care's care 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: December 27, 2024
Observations: Licensing audited six person in care's care plans, and four person in care's care plans did not include a recreation and leisure plan.
3070 - RCR 81(3)(e)(ii)
Description: A care plan must include all of the following: in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, a fall prevention plan, which must address a plan for preventing the person in care from falling
Corrective Actions Required: Ensure that, in the case of a person in care who receives a type of care described as Long Term Care or who may be prone to falling, that there is a fall prevention plan that addresses a plan for preventing a person in care from falling.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 27, 2024
Observations: Licensing audited six person in care's care plans. One person in care who was at risk for falling, did not have a fall prevention plan included in the care 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 that if a person in care has been determined to be at risk of leaving a community care facility without notification of an employee, there is a plan if the person in care leaves without notification, to locate the person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 27, 2024
Observations: Licensing audited six person in care's care plans. One person in care who was at risk of going missing, did not have a plan to locate the person in care if they went missing.
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 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: December 27, 2024
Observations: Licensing audited the medication on the second and third floors and observed one medication that had expired and had not been returned to the dispensing pharmacy.