Dr. G.S. Cheema Infection Control Inspection


Summary

Improper use of biological and chemical indicators for reprocessing. Medical instruments in disrepair. An order was issued on May 21, 2019 to ensure compliance.

Diseases resulting from similar errors in infection control may include:

  • Blood-borne infections
  • Skin / soft tissue infections
  • Sexually transmitted infections

Contact

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


Findings and Corrective Measures

A complaint was identified from a member of the public on May 15, 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 May 21, 2019.

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

Ongoing Issues

IssueCorrectionLast Updated
Education and training of infection control policies, procedures not provided or documented for all staff.Education and training to be provided and documented on a regular basis.May 31, 2019

Corrected Issues

IssueCorrectionDate Corrected
Written infection control policies and procedures were incomplete. Infection prevention and control policies that are based on current best practices are available, reviewed and updated on a routine basis.Dec. 13, 2019
Cleaning brushes not used to clean equipment during reprocessing.Cleaning brushes to be used to sufficiently clean tools prior to sterilization and is cleaned, disinfected, dried and stored after each use, or discarded.July 4, 2019
Reprocessing area not sufficient in space to follow a one-way work flow.Reprocessing area space to follow a one-way work flow from dirty to clean. July 4, 2019
Eyewash station not provided and located within a 10-second walk of reprocessing area.Eyewash station to be available and located within a 10-second walk of reprocessing area.July 4, 2019
Needles for injection not safety-engineered.Needles for injection are safety-engineered.July 4, 2019
Medications not prepared in a clean area separate from other areas.Prepare medications in a clean area on a clean surface. July 4, 2019
Floor surface in exam room(s) not cleanable.Floor surfaces in exam room(s) are to be of material that can be cleaned and disinfected.July 4, 2019
Personal protective equipment (PPE) not available in exam and reprocessing areas.PPE to be available for use in exam and reprocessing areas.July 4, 2019
Non-critical items that may become contaminated or come in contact with patient not cleaned and disinfected between patients.Non-critical items that can become contaminated during patient exam or after patient contact are cleaned and disinfected or barriers used.July 4, 2019
No safety data sheets available for cleaning/disinfecting products.Safety data sheets for cleaning/disinfecting products to be readily available and up-to-date.July 4, 2019
Medical instruments for sterilization in disrepair. ORDER has been issued to ensure compliance. As of May 24, 2019, all contents of the order have been satisfied.Repair or discard medical instruments.May 24, 2019
Packaged, sterilized medical equipment not stored in a manner that keeps them clean, dry, and prevents contamination.Packaged, sterilized critical medical equipment to be stored securely in a manner that keeps equipment clean, dry, and prevents contamination.May 24, 2019
A log of test results, parameters and maintenance during sterilization not kept.Record and maintain appropriate results on log sheet.May 24, 2019
Sterilized packages not labelled. Sterilized packages labelled with date processed, cycle or load number and the health care provider’s initials. May 24, 2019
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 date opened and discarded as per manufacturer expiry date.May 24, 2019
Furnishings within exam room(s) are porous and not cleanable material.Furnishing within exam rooms are to be of porous and cleanable material.May 24, 2019
Clean medical supplies stored on counters adjacent to sink.Clean medical supplies to be stored in a clean, dry area away from contamination.May 24, 2019
The sterilizer not tested with a biological indicator each day the sterilizer is used. ORDER has been issued to ensure compliance. As of May 24, 2019, all contents of the order have been satisfied.The sterilizer to be tested with a biological indicator each day the sterilizer is used.May 22, 2019
Medical equipment placed in locked, unopened position and overlapping in packages for sterilization.All medical equipment to be placed in unlocked, opened position and not overlapping in packages for sterilization.May 22, 2019
Type 5 Integrators were not used appropriately to justify the release of routine loads. Type 5 Integrators placed in each pouch undergoing sterilization.May 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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