The use of a sterilizer for reprocessing instruments did not follow best practices. Inadequate packaging, quality assurance and documentation during reprocessing.
Diseases resulting from similar errors in infection control may include:
Public Health Inspector
905-980-6000 ext. 7590, toll free 1-888-505-6074
A referral was made by on August 6, 2021, related to infection prevention and control concerns.
This infection prevention and control lapse involved a member of the regulatory college.
Orally corrective measures were discussed at the time of inspection.
An initial onsite investigation was conducted on August 9, 2021.
An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.
|Written infection control and reprocessing policies and procedures were incomplete.||Infection control and reprocessing policies that are based on current best practices to be available, reviewed and updated on a routine basis.||Oct. 22, 2021|
|No process in place for receiving and disseminating medical equipment/device alerts and recalls or contingency plans in the event of a sterilizer failure.||Create a process for receiving and disseminating medical equipment/device alerts and recalls or contingency plans in the event of a sterilizer failure.||Oct. 22, 2021|
|The sterilizer not tested with a biological indicator each day the sterilizer is used.||Sterilizer to be tested with a biological indicator each day the sterilizer is used. ORDER has been issued on August 9, 2021 to ensure compliance||Oct. 22, 2021|
|A log of test results, parameters, and maintenance during sterilization not kept.||A log of test results, parameters, and maintenance during sterilization to be kept.||Oct. 22, 2021|
|Medical equipment with multiple components not disassembled for sterilization.||Medical equipment that has multiple components to be disassembled for sterilization.||Oct. 22, 2021|
|Medical equipment placed in locked and unopened position in packages for sterilization||Medical equipment to be placed in locked and unopened position in packages for sterilization||Oct. 22, 2021|
|Sterilization packages not labelled appropriately.||Sterilization packages to be labelled appropriately.||Oct. 22, 2021|
|Medical equipment not packaged according to manufacturer’s instructions for use.||Medical equipment to be packaged according to manufacturer’s instructions for use.||Oct. 22, 2021|
|Opened multi-dose medication vials not used for a single-patient and not labelled with date opened and discarded as per expiry date.||Multi-dose medication vials to be single patient use and labelled with date opened and discarded as per manufacturer’s expiry date.||Oct. 22, 2021|
|Education and training of infection control and reprocessing policies, procedures not provided or documented for all staff.||Education and training to be provided and documented on a regular basis.||Oct. 22, 2021|
|Eyewash fountain not capable of operating hands-free.||Eyewash fountain to be capable of operating hands-free.||Oct. 22, 2021|
|Sterilizer did not have mechanical display, print-out, or USB to allow for cycles to be verified.||A new sterilizer with a mechanical display has been obtained.||Aug. 12, 2021|
|Personal protective equipment (PPE) not readily accessible.||PPE to be made readily accessible.||Aug. 12, 2021|
|Medications not stored and prepared in a clean area.||Medications to be stored and prepared in a clean area.||Aug. 12, 2021|
|There was not a regular cleaning schedule in the dedicated reprocessing area||A regular cleaning schedule in the dedicated reprocessing area to be implemented||Aug. 12, 2021|
|Sterilization packages not stored in a manner to prevent contamination.||Packaged, sterilized instruments shall be stored in a manner that prevents contamination.||Aug. 10, 2021|
|Clean medical supplies/equipment stored under sink(s).||Clean medical supplies to be stored in a clean, dry area away from contamination.||Aug. 10, 2021|
|Furnishings not cleanable.||Furnishings to be cleanable.||Aug. 10, 2021|
|Dedicated hand washing sink not used for handwashing only.||Dedicated hand washing sink to be used for hand washing only.||Aug. 9, 2021|
|There was not a dedicated medication refrigerator that was separate from food.||Premise no longer requires medication refrigerator.||Aug. 9, 2021|
|Alcohol-based hand rub not available in reprocessing work area.||Alcohol-based hand rub to be provided in reprocessing work area.||Aug. 9, 2021|
In the event that a direct health risk is identified for clients who visited this establishment, Niagara Region Public Health will contact those at risk with advice around any medical follow-up.
For general updates regarding this investigation, continue to monitor this website.