Niagara Detention Center Infection Control Inspection
- Address
1355 Uppers Lane
Thorold - Services
Dentist
Summary
Dental instruments not packaged for sterilization in a way that the steam can move around and through the items and contact all surfaces. Instruments not pre-cleaned or packaged appropriately for sterilization. Parameters for sterilization not maintained/recorded.
Diseases resulting from similar errors in infection control may include:
- Blood-borne 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 October 21, 2024, 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 October 23, 2024.
An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.
Ongoing Issues
| Issue | Correction | Last Updated |
|---|---|---|
| Sterilization record(s) not maintained and reviewed. | Maintain and review sterilization record(s). | Oct. 23, 2024 |
| There is no designated reprocessing area. | Designate an appropriate reprocessing area. | Oct. 23, 2024 |
| There is not a one-way workflow from dirty to clean. | Implement a one-way workflow from dirty to clean. | Oct. 23, 2024 |
| Medical equipment/devices not pre-cleaned before they are transported to the reprocessing area. | Pre-clean medical equipment/devices at point of use before transport. | Oct. 23, 2024 |
| Dirty equipment/devices not cleaned immediately after use not kept moist. | Store dirty equipment/devices that cannot be cleaned immediately moist in a sealed container. | Oct. 23, 2024 |
| Medical/dental equipment/devices not cleaned appropriately. | Clean medical equipment/devices appropriately. | Oct. 23, 2024 |
| Cleaning equipment (i.e. brushes) are not cleaned or disinfected. | Multi-use cleaning equipment to be cleaned and disinfected after each use. | Oct. 23, 2024 |
| Cleaning equipment not stored properly | Cleaning equipment to be stored in an area away from clean and sterilized equipment/devices. | Oct. 23, 2024 |
| Single use cleaning equipment not discarded after use. | Cleaning equipment to be discarded if unable to clean and disinfect. | Oct. 23, 2024 |
| Single-use critical and semi-critical [dental/medical equipment/devices not disposed of immediately after use. | Discard single-use critical and semi-critical dental/medical equipment/devices immediately after use. | Oct. 23, 2024 |
| Critical and preferably semi-critical dental/medical equipment/devices not sterilized appropriately. | Sterilize critical and preferably semi-critical dental/medical equipment/devices appropriately. | Oct. 23, 2024 |
| Qualification/Re-qualification of sterilizer on-site not done appropriately. | Qualify/re-qualify the sterilizer on-site appropriately. | Oct. 23, 2024 |
| Dental/medical equipment/devices not packaged appropriately. | Package dental/medical equipment/devices to allow steam to contact all surfaces. | Oct. 23, 2024 |
| Dental/medical equipment/devices not disassembled for sterilization. | Disassemble dental/ medical equipment/devices prior to sterilization. | Oct. 23, 2024 |
| Dental/medical equipment/devices are in the locked and closed position for sterilization. | Unlock and open dental/medical equipment/devices to sterilize appropriately. | Oct. 23, 2024 |
| Packages undergoing sterilization not labeled appropriately. | Label packages undergoing sterilization appropriately. | Oct. 23, 2024 |
| Chemical Indicators not used appropriately during the sterilization process. | Chemical Indicators to be used appropriately for every package undergoing sterilization. | Oct. 23, 2024 |
| Dental/medical equipment/devices not sterilized appropriately. | Sterilize medical/dental equipment/devices according to the Manufacturer’s Instructions for Use. | Oct. 23, 2024 |
| Sterilizer cycles not verified appropriately. | Verify sterilization record(s) for each cycle. | Oct. 23, 2024 |
| Sterilizer not tested with a Biological Indicator appropriately. | Appropriately test sterilizer with a Biological Indicator. | Oct. 23, 2024 |
| Sterilizer not tested with a control Biological Indicator appropriately. | Appropriately test sterilizer with a control Biological Indicator | Oct. 23, 2024 |
| Every sterilizer load containing an implantable device not tested with a Biological Indicator. | Test every sterilizer load containing an implantable device with a Biological Indicator. | Oct. 23, 2024 |
| Dental/medical equipment/devices undergoing sterilization not quarantined appropriately. | Quarantine dental/medical equipment/devices undergoing sterilization appropriately. | Oct. 23, 2024 |
| There are no contingency plans in the event of a sterilizer failure. | Contingency plans are required in the event of a sterilizer failure. | Oct. 23, 2024 |
| Processed packages that are contaminated not reprocessed as appropriate. | Reprocess all contaminated processed packages. | Oct. 23, 2024 |
| Chemical Indicator(s) not checked prior to using the sterilized dental/medical equipment/devices. | Do not use sterilized dental/medical equipment/devices until the Chemical Indicator(s) on each have been checked. | Oct. 23, 2024 |
| The level of education and training not adequate. | Education and training is to be provided based on the tasks performed. | Oct. 23, 2024 |
| Device-specific reprocessing instructions from the device manufacturer are incomplete/not available | Device-specific reprocessing instructions from the device manufacturer are to be available. | Oct. 23, 2024 |
| Continuing education as required/needed is incomplete/not available | Continuing education as required/needed is to be complete/available | Oct. 23, 2024 |
| Records of training and education is incomplete/not available. | Records of training and education are to be complete/available. | Oct. 23, 2024 |
| There are no designated individual(s) responsible for reprocessing with the required training. | There are to be designated individual(s) responsible for reprocessing with the required training. | Oct. 23, 2024 |
| No barriers used on difficult to clean high touch surfaces/equipment. | Barriers/covers to be used on high touch surfaces/equipment that may become contaminated. | Oct. 23, 2024 |
| Barriers/ covers not removed and discarded between clients. | Barriers/covers to be removed and discarded between clients. | Oct. 23, 2024 |
| Upon removal of barriers/covers from surfaces, the area underneath not cleaned and disinfected appropriately. | Upon removal of barriers/covers from surfaces, the area underneath to be cleaned and disinfected as appropriate. | Oct. 23, 2024 |
| Non-critical items not cleaned and disinfected appropriately. | Clean/disinfect non-critical items as appropriate. | Oct. 23, 2024 |
| Semi-critical and critical instruments/items not cleaned and disinfected appropriately. | Semi-critical and critical instruments/items are cleaned and disinfected appropriately. | Oct. 23, 2024 |
| Critical and/or semi-critical instruments were not heat-tolerant and/or single use. | All critical and semi-critical instruments are heat tolerant and/or single use. | Oct. 23, 2024 |
| Single-use items are not disposed of following use. | Dispose of single-use items following use. | Oct. 23, 2024 |
| Impressions, prostheses or appliances not cleaned and disinfected promptly after removal from the mouth. | Impressions, prostheses or appliances are to be cleaned and disinfected promptly after removal from the mouth. | Oct. 23, 2024 |
| Heat-tolerant items used in the mouth not sterilized after each patient/client use. | Heat-tolerant items used in the mouth are to be sterilized after each patient/client use. | Oct. 23, 2024 |
| Other items that do not come in contact with the client/patient not cleaned and disinfected according to the manufacturer’s instructions for use. | Other items that do not come in contact with the client/patient are to be cleaned and disinfected according to the manufacturer’s instructions for use. | Oct. 23, 2024 |
| The written infection prevention and control policies and procedures are incomplete/not available. | Written infection prevention and control policies and procedures are to be available. | Oct. 23, 2024 |
| Written infection control policies and procedures are not based on current best practices. | Written infection control policies and procedures are to be based on current best practices. | Oct. 23, 2024 |
| Staff have not received office-specific training in infection prevention and control when required. | Staff are to receive office-specific training in infection prevention and control when required. | Oct. 23, 2024 |
| Training has not been completed whenever necessary or reviewed at least annually. | Training is to be completed whenever necessary or reviewed at least annually. | Oct. 23, 2024 |
| The employer(s), supervisor(s) and worker(s) unaware of hazards/dangers relating to work safety. | Employer(s), supervisor(s) and worker(s) to be aware of workplace hazards to ensure work safety. | Oct. 23, 2024 |
| There is no process for recording attendance of education and training. | A process is to be available to record attendance of education and training. | Oct. 23, 2024 |
| Eyewash station is not provided. | An eyewash station must be provided. | Oct. 23, 2024 |
| The eyewash fountain/station is not located within a 10-second walk of the reprocessing area. | The eyewash fountain/station is to be located within a 10-second walk of the reprocessing area. | Oct. 23, 2024 |
Corrected Issues
| Issue | Correction | Date Corrected |
|---|---|---|
| Personal protective equipment not available in various sizes, or at point of care. | Personal protective equipment to be provided in various sizes and at point of care. | Nov. 13, 2024 |
| Personal protective equipment not worn correctly based on point of care risk assessment. | Personal protective equipment to be worn correctly based on exposure risk/point of care risk assessment. | Nov. 13, 2024 |
| Work surfaces not appropriate. | Install appropriate work surfaces. | Nov. 13, 2024 |
| Hand washing sinks/alcohol-based hand rub is not located in or near reprocessing area(s). | Hand washing sinks/alcohol-based hand rub located in or near the reprocessing area(s). | Nov. 13, 2024 |
| Chemical products used for disinfection or sterilization not appropriate. | Chemical products used for disinfection and sterilization are to be appropriate and used as per Manufacturer's Instructions for Use. | Nov. 13, 2024 |
| Disinfectants used past expiry date. | Disinfectants are not used past the expiry date. | Nov. 13, 2024 |
| A process to address alerts and recalls originating from the manufacturer(s) or government agencies is incomplete/ not available. | A process to address alerts and recalls originating from the manufacturer(s) or government agencies is to be complete/available. | Nov. 13, 2024 |
| A process to ensure recall has occurred is incomplete/not available. | A process to ensure recall has occurred is to be complete/ available. | Nov. 13, 2024 |
| Chemical products used/stored on site are not appropriate. | Use/store chemical products on site appropriately, as per MIFU. Chemical products used for environmental cleaning are to be licensed in Canada | Nov. 13, 2024 |
| Personal protective equipment not available in clinic setting at point of care. | Provide personal protective equipment in clinic setting at point of care. | Nov. 13, 2024 |
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.
© Niagara Region - 1815 Sir Isaac Brock Way, Thorold, ON, L2V 4T7 - Phone: 905-980-6000, Toll-free: 1-800-263-7215
