Dr. M. Yegappan, MB, MRCOG, FRCS © Infection Control Inspection


Inadequate quality assurance and documentation during reprocessing. Insufficient documentation of IPAC policies and procedures. Expired Alcohol Based Hand Rub (ABHR) and disinfectant products.

Diseases resulting from similar errors in infection control may include:

  • Blood-borne infections
  • Skin / soft tissue infections


Public Health Nurse
Public Health Nurse
905-980-6000 ext. 7330, toll free 1-888-505-6074

Findings and Corrective Measures

A complaint was identified from a member of the public on March 20, 2019, 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 March 21, 2019.

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

Corrected Issues

IssueCorrectionDate Corrected
Expired Alcohol Base Hand Rub (ABHR) observed in the clinic rooms. Bar soap observed in the patient washroom.Replace expired ABHR bottles. Liquid soap is to be provided at every hand wash sink.April 26, 2019
Written infection control policies and procedures were incomplete. Provide infection prevention and control policies that are based on current best practices. Review and update on a routine basis.April 26, 2019
Education and training not provided and documented for all infection control practices.Education and training to be provided and documented. April 26, 2019
Personal Protective Equipment (PPE) was not readily accessible in the reprocessing area. PPE to be available for use in the reprocessing area. April 3, 2019
Disinfectants observed past their expiry date.Replace expired disinfectants.April 3, 2019
A log of test results during sterilization was not maintained.Record BI and Type 5 Integrators test results on a log sheet.March 25, 2019
The sterilizer is not tested with a BI each day the sterilizer is used. ORDER has been issued to ensure compliance. As of March 25, 2019, all contents of the order have been satisfied.The sterilizer to be tested with a BI each day the sterilizer is used.March 22, 2019
Type 5 Integrators were not used appropriately to justify the release of routine loads. Type 5 Integrators to be placed in each pouch undergoing sterilization.March 22, 2019

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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