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
February 21, 2024
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
3010 - DOLSOP (Prevent Overdose Deaths)
Description: Staff Trained Ensure that trained staff are available to administer Naloxone to persons in care when persons in care are on the premises of the licensed facility or away from the premises and remain under the care of facility staff.
Corrective Actions Required: Ensure that trained staff are available to administer Naloxone to persons in care when persons in care are on the premises of the licensed facility or away from the premises and remain under the care of facility staff
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2024
Observations: This item has been carried forward from Routine Inspection dated August 5, 2022. Licensing observed that one person in care was prescribed an opioid medication. There was no Naloxone kit on site and the Manager stated that staff had not been trained to administer Naloxone.
3010 - RCR 40(1)(b)
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 demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Required: Ensure that the performance of each employee is reviewed both regularly and as directed by the medical health officer to ensure that the employee demonstrates the competence required for the duties to which the employee is assigned.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2024
Observations: This item has been carried forward from Routine Inspection dated August 5, 2022. This item was unable to be corrected today as staff files were not audited due to being located at the head office.
3020 - RCR 85(1)(b)
Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year
Corrective Actions Required: Ensure to review and if necessary, revise the policies and procedures at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2024
Observations: This item has been carried forward from Routine Inspection dated August 5, 2022. Licensing reviewed the policy and procedure binders and with the exception of two policies, the majority had not been reviewed in the last year.
3030 - RCR 83(5)(a)
Description: If a person in care refuses or is unable to be weighed, the licensee must record in the nutrition plan of the person in care the reason why the person in care was not weighed
Corrective Actions Required: If a person in care refuses or is unable to be weighed, ensure to record in the nutrition plan of the person in care why the person in care was not weighed.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2024
Observations: This item has been carried forward from Routine Inspection dated August 5, 2022. Licensing audited two care files. Two persons in care did not have monthly weights on file.
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 each month.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: May 21, 2024
Observations: This item has been carried forward from Routine Inspection dated August 5, 2022. Licensing audited two person in care's charts. Both persons in care did not have monthly weights on file.
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: May 21, 2024
Observations: Licensing audited the medication cabinet and found several expired medications.