The use of a sterilizer for reprocessing, packaging of sterile insruments and use of a single-use lancing device did not follow best practices.
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 complaint was identified from a member of the public on April 8, 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 April 9, 2021.
An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.
|Opened multi-dose medication vials not labelled with date opened and discarded as per expiry date.||Multi-dose medication vials are to be labelled with daet opened and discarded as per manufacturer expiry date.||May 11, 2021|
|Eyewash fountain not cabable of operating hands-free.||Eyewash fountain to be capable of operating hands-free.||May 11, 2021|
|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.||May 11, 2021|
|Clean medical supplies/equipment stored under sink(s).||Clean medical supplies to be stored in a clean, dry area away from contamination.||May 6, 2021|
|Specimens and transport containers not labelled and stored appropriately. Specimens not transported in a leak-proof continer.||Specimens and transport containers labelled and stored appropriately and transported in a leak-proof container||May 6, 2021|
|Medical equipment/devices not kept moist when cleaning could not be done immediately.||Medical equipment/devices to be kept moist in a containter if cleaning cannot be done immediately.||April 16, 2021|
|Personal protective equipment not selected and used appropriately.||Select and use personal protective equipment based on risk assessment.||April 16, 2021|
|Medications not stored in an area separate from non-authorized persons.||Store/Prepare medications and supplies in an area separate from non-authorized persons.||April 16, 2021|
|Medication instructions for use not acessible.||Medication instructions for use to be accessible.||April 16, 2021|
|Specimins not stored ina dedicated refrigerator||Store specimines that require refrigeration in a dedicated specimin refrigerator||April 16, 2021|
|Barriers that come into contact with clients not replaced or discarded between use.||Barriers that come into contact with clients to be replaced or discarded between use.||April 16, 2021|
|The sterilizer not tested with a biological indicator each day the sterilizer is used. ORDER has been issued to ensure compliance. As of April 13, 2021, all contents of the order have been satisfied.||The sterilizer no longer used on-site.||April 13, 2021|
|Lancing devices and holders not used in accordance with manufacturer's instructions for use. ORDER has been issued to ensure compliance. As of April 13, 2021, all contents of the order have been satisfied.||The lancing device and holder no longer used and moved off site.||April 13, 2021|
|A log of test results, parameters and maintenance during sterilization not kept.||The sterilizer no longer used on-site.||April 13, 2021|
|Reprocessing area not sufficient in space to follow a one-way work flow.||Reprocessing area to have sufficient counters and space to follow a one-way work flow from dirty to clean.||April 13, 2021|
|Medical equipment placed in locked and unopened position in packages for sterlization and not maintained in sterile packaging prior to use.||The sterilizer no longer used on-site.||April 13, 2021|
|Urine speciments not processed in a designated area.||Process and handle urine specimins in a designated area.||April 13, 2021|
|Manufacturer's instruction for use not followed for operation of sterilizer and its associated equipment.||The sterilizer no longer used on-site.||April 13, 2021|
|Sterilized packages not labelled.||The sterilizer no longer used on-site.||April 13, 2021|
|Type 5 integrators were not used appropriately to justify the relase of the routine loads.||The sterlizer no longer used on-site.||April 13, 2021|
|There was not a process for receiving and disseminating medical equipment/device alerts and recalls originating from the manufacturer or government agencies or contingency plans in the event of a sterilizer failure.||The sterilizer no longer used on-site.||April 13, 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.||April 13, 2021|
|Hand santizer not available at point of care and hands not cleaned appropriately||Hand sanitizer to be available at point of care and hands to be cleaned appropriately.||April 9, 2021|
|Dedicated hand washing sink not used for handwashing only.||Dedicated hand washing sink to be used for hand washing only.||April 9, 2021|
|Cleaning/disinfecting products not used according to manufacturer's instructions for use.||Use clenaing/disinfecting products as described in the manufacturer's instructions for use.||April 9, 2021|
|Tissue boxes not available in the reception/waiting area.||Tissue boxes to be available in the reception/waiting area.||April 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.