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
December 13, 2021
Contraventions:
A summary of the new or corrected contraventions found during the inspections are listed below.Code
Category/Description
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, 2021
Observations: Licensing audited the electronic Medication Administration Record (eMAR). The eMAR indicated on person in care's morning medications were not signed for on December 10, 2021.
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 that all policies and procedures are reviewed or revised at least once each year.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By:
Observations: Licensing audited the policy and procedures. All policies and procedures were dated January 2018 or November 2020.
3060 - DOLSOP (Immunization Records)
Description: Clear and up to date records of immunization status kept for each person in care
Corrective Actions Required: Ensure that there are clear & up to date records of immunization for each person in care.
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 27, 2021
Observations: Licensing audited three person in care's files. One person in care's file did not have a record of immunization.
3070 - RCR 81(3)(e)(iii)
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 following up on any falls suffered by a person in care
Corrective Actions Required:
Corrective Actions Taken By Licensee:
Actions Required By Licensing: Follow Up Inspection to be conducted.
To Be Corrected By: December 20, 2021
Observations: Licensing audited three person in care's care plans on this date. All three care plans did not have a plan on how to follow up on falls suffered.