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Dr. Nambizi Namuya Beyani Mulaisho Infection Control Inspection


Summary

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:

  • Blood-borne infections
  • Skin / soft tissue infections

Contact

Duty Officer
Public Health Inspector
905-980-6000 ext. 7590, toll free 1-888-505-6074
inspect@niagararegion.ca


Findings and Corrective Measures

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.

Ongoing Issues

IssueCorrectionLast Updated
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

Corrected Issues

IssueCorrectionDate Corrected
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 complianceOct. 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 areaA regular cleaning schedule in the dedicated reprocessing area to be implementedAug. 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

Health Risks and Inspections

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.

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