| Peace Arch Hospital ECU - Complaint Information |
| General Details | |
|---|---|
| Facility Type | Residential Care (Hospital Act) - 400 |
| Investigation Completed | September 16, 2022 |
| Reason for Investigation | - Policies and procedures - Care and supervision |
| Report of Findings |
|---|
| On July 4, 2022 Licensing received a complaint alleging concerns related to policies and procedures, and care and supervision. The allegations included the following details: Policies and Procedures: - Personal belongings were removed from the facility. Care and Supervision: - Staff failed to ensure a person in care (PIC) could not slide out of their wheelchair and ensure comfortable positioning while in the wheelchair. - Staff were not changing a PIC's incontinent pads regularly. - A PIC had a condition due to constant touching of the eyes. - A PIC had a possible medical condition that was not assessed by a Medical Practitioner. All areas of the complaint were thoroughly investigated. Evidence was received and reviewed from interviews, correspondence with the facility, and inspection. The following contraventions were determined: - Residential Care Regulation - Section 85 (1)(d) Policies and procedures. |
| Substantiated Contraventions: Evidence for this summary report is based on a combination of the Licensing Officer’s observations, a review of facility records and information provided by the facility staff at the time of the investigation. |
| Observed Violations/Contraventions: A summary of the violations found during the complaint investigation are listed below. |
| Code | Category/Description |
|---|---|
| 33280 - RCR s.85(1)(d) | A licensee must do all of the following: (d) ensure that policies are implemented by employees. Observation: It was determined that staff failed to document entries on the care flow sheets and the fall risk assessment was incomplete for a person in care. Corrective action: Corrective action required. |
| Actions Required by Licensee/Operator | |
|---|---|
| - Corrective action plan to be developed and submitted. |
| Action Required by Licensing Officer or Medical Health Officer | |
|---|---|
| - Review and monitor corrective action plan > Follow up inspection required. |
| Status Update |
|---|
| No further action required. All contraventions have been addressed. |
| Updated on October 03, 2022. |
