Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.

Community Care Facilities Licensing
FACILITY INSPECTION REPORT
HEALTH & SAFETY
CJOS-C7GVY2
FACILITY NAME
George Derby Centre		SERVICE TYPES
130 Long Term Care
FACILITY LICENSE #
3203592
FACILITY ADDRESS
7550 Cumberland St		FACILITY PHONE
()
CITY
POSTAL CODE
MANAGER
Ava Turner
INSPECTION DATE
October 04, 2021		ADDITIONAL INSP. DATE (multi-day)
ADDITIONAL INSP. DATE (multi-day)
TIME SPENT (HRS.)
3
ARRIVAL
01:00 PM		DEPARTURE
03:30 PM		ARRIVAL
DEPARTURE
ARRIVAL
DEPARTURE
INSPECTION TYPE
Follow-up		# OBSERVED IN CARE
Introduction

An unscheduled follow up inspection to the Routine Inspection, dated March 24, 25, and 26th, 2021, was conducted. Areas of non-compliance identified at the Routine Inspection were reviewed for compliance.
Visit the CCFL website at www.fraserhealth.ca/residentialcare
for:
· Additional resources, and
· Links to the Legislation (CCALA and RCR)
Contraventions
Previous Inspection -
Current Inspection - Items reviewed comply with the Act, regulations & standards of practice except for those noted on supplementary pages.
Observed Violations
STAFFING: 32320 - RCR s.68(4) - A licensee must ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Observation: Review of medication administration and documentation practices found that the narcotic count book was missing evidence of a double signature as required by the medication administration policy. There was also an instance whereby the entry was incorrectly dated. It was noted that there was one missing entry and one incorrect entry, which is an improvement from the previous inspection.
Review of the narcotic documentation policy is ongoing with all nursing staff, specifically new staff and there are ongoing compliance audits.
Corrective Action(s): Ensure that all employees comply with the policies and procedures of the medication safety and advisory committee.
Date to be Corrected: October 6, 2021.

CARE AND/OR SUPERVISION: 34780 - RCR s.82 - A licensee must ensure that the care and supervision of a person in care is consistent with the terms and conditions of the person in care's care plan.
Observation: Review of wound care treatment plans found there to be 3 instances whereby the documentation of treatment provided was not in accordance with the treatment plan. Specifically it was related to frequency of treatment and there was no documentation to indicate the reason this did not occur.
Education for staff is ongoing, focusing on new staff. Specific instruction to ensure staff are documented when treatment cannot be provided. Compliance audits are ongoing.
Corrective Action(s): Ensure that care and supervision of a person in care is in accordance with the terms and conditions of the person in care's care plan.
Date to be Corrected: October 6, 2021
Comments

The facility was able to show evidence of creating and implementing systems to self-monitor the facility and the care and services provided by it. The systems include auditing and evaluating information to ensure its continued validity. Although 2 repeat contraventions have been identified, no new action plan is required. There is confidence that the current compliance plan, coupled with continued training for a significant number of staff recently on-boarded, will ensure increase consistency with compliance moving forward.
Thank you to the staff for their time and assistance in completing this inspection report.
Due to infection control protocols currently in place due to COVID-19, this report was completed off-site and an email copy was provided to facility leadership.
Action Required by Licensee/ManagerAction Required by Licensing Staff
Take corrective action to bring facility into compliance, Provide a written response to LicensingNo action required
Due Date
Oct 06, 2021
Click here for FAQ About Inspections.
Click here for a description of each "Category" of violation displayed.