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)
Follow-Up
August 16, 2022
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3000 - RCR 17
Description: A licensee must ensure that water accessible to a person in care, from any source, is not heated to more than 49° Celsius.
Corrective Actions Required:
Corrective Actions Taken By Licensee: Licensing tested the hot water in four sinks where person in care had access to hot water and the temperature were below 49 degrees Celsius.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 all rooms and common areas are maintained and 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: August 1, 2022
Observations: Licensing toured the facility and observed a broken light fixture in a person in care's room, damage to baseboard strips in two person in care's room, and the hot water not working in a person in care's bathroom.
3010 - RCR 44(2)(a)
Description: A licensee who accommodates 50 or more persons in care in a community care facility must have, to supervise the preparation and delivery of food, a food services manager who is a nutrition manager with membership in the Canadian Society of Nutrition Management,
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: An exemption to this section was approved by the Licensing program on August 9, 2022.
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:
Corrective Actions Taken By Licensee: Licensing audited the Narcotic count in the first and second floor nursing station. All Narcotic counts were completed fully and signed by staff.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations:
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 each person in care has, in writing, consent 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 Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: August 1, 2022
Observations: Licensing audited eight person in care's charts. Three person's in care did not have a record of written consent to call a medical or nurse 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 care plans for all person's in care include a recreation and leisure plan.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: July 25, 2022
Observations: Licensing audited eight care plan's. Four person in care were missing 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:
Corrective Actions Taken By Licensee: Licensing audited five person in care's care plan's, one person in care who is at risk for missing/wandering had a plan to locate the person in care if they were missing.
Actions Required By Licensing: No further action required; this contravention has been addressed.
To Be Corrected By:
Observations: