Niagara North Family Health Team Infection Control Inspection

Address
1338 Fourth Ave Suite S100
St. Catharines
Services
Physician

Summary

Inadequate sterilization of critical/semi-critical tools Single use critical/semi-critical tools being reprocessed

Diseases resulting from similar errors in infection control may include:

Blood-borne infections
Skin / soft tissue infections
Sexually transmitted 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 November 15, 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 November 27, 2024.

An investigation report was given to the premise / facility noting corrective measures. Information and education was provided.

Corrected Issues

Issue	Correction	Date Corrected
Sterilization record(s) not maintained and reviewed.	Maintain and review sterilization record(s).	Feb. 3, 2025
No written policy and procedure available detailing the regular cleaning schedule of the reprocessing area.	Provide a written policy and procedure detailing the regular cleaning schedule of the reprocessing area.	Feb. 3, 2025
Single-use critical and semi-critical devices/equipment are being reprocessed/reused.	Single-use critical and semi-critical medical equipment/devices to be discarded immediately after use.	Feb. 3, 2025
Qualification/Re-qualification of sterilizer on-site not done appropriately.	Qualify/re-qualify the sterilizer on-site appropriately.	Feb. 3, 2025
Medical equipment/devices not packaged to appropriately allow steam to contact all surfaces.	Medical equipment/devices not packaged to appropriately allow steam to contact all surfaces.	Feb. 3, 2025
Packages undergoing sterilization not labeled appropriately.	Label packages undergoing sterilization appropriately.	Feb. 3, 2025
Chemical Indicators not used appropriately during the sterilization process.	Chemical Indicators to be used appropriately for every package undergoing sterilization.	Feb. 3, 2025
Sterilizer cycles not verified appropriately.	Verify sterilization record(s) for each cycle.	Feb. 3, 2025
Sterilizer not tested with a Biological Indicator appropriately.	Appropriately test sterilizer with a Biological Indicator.	Feb. 3, 2025
Medical equipment/devices undergoing sterilization not quarantined appropriately.	Quarantine medical equipment/devices undergoing sterilization appropriately.	Feb. 3, 2025
There are no contingency plans in the event of a sterilizer failure.	Contingency plans required in the event of a sterilizer failure.	Feb. 3, 2025
Processed packages not allowed to dry inside the sterilizer chamber.	Allow processed packages to dry inside the sterilizer chamber.	Feb. 3, 2025
Processed packages that are contaminated not reprocessed appropriately.	Reprocess all contaminated processed packages.	Feb. 3, 2025
Policies and procedures for all aspects of reprocessing are not written,current or reviewed regularly on recognized standards/recommendations/MIFU as they become available.	Written policies and procedures for all aspects of reprocessing are current and are reviewed regularly on the standards/recommendations/MIFU as they become available.	Feb. 3, 2025
Laundry handled in a way that may lead to contamination.	Laundry to be handled in a way to prevent contamination.	Feb. 3, 2025
Non-critical items not cleaned and disinfected appropriately.	Clean/disinfect non-critical items as appropriate.	Feb. 3, 2025
Multidose vial not labelled appropriately and not discarded according to the manufacturer’s instructions for use/ within 28 days.	Label multidose vial appropriately and discard multidose vial according to the manufacturer’s instructions for use/within 28 days.	Feb. 3, 2025
Multi-dose non-sterile gel containers not properly labeled and identified.	Multi-dose non-sterile gel containers to be labeled appropriately and discarded after 30 days or as per MIFU.	Feb. 3, 2025
Specimens not stored in an appropriate area of the clinic.	Store specimens in a designated area, separate from clean supplies.	Feb. 3, 2025
Single-client use glucometer used for multiple clients.	Single-client use glucometer only to be used for one client.	Feb. 3, 2025
Clean medical supplies are observed to be stored on counter adjacent to sink and found under the sink.	Clean medical supplies are to be stored away from sink and adjacent areas.	Dec. 6, 2024
Disinfectants used past expiry date.	Disinfectants not to be used past their expiry date.	Nov. 27, 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.