Minor Emerg Walk-in Clinic Infection Control Inspection


Summary

The use of a sterilizer for reprocessing, packaging of sterile instruments and use of injectable medication did not follow best practices.

Diseases resulting from similar errors in infection control may include:

  • Blood-borne infections
  • Skin / soft tissue 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 June 4, 2020, 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 June 12, 2020.

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

Corrected Issues

IssueCorrectionDate Corrected
Medical equipment were not stored sterile until point of use.Medical equipment must be maintained as sterile until point of use.Sept. 4, 2020
Needles for injection not safety-engineered.Needles for injection to be safety-engineered.Sept. 4, 2020
Furnishings within exam rooms not cleanable.Furnishing within exam rooms to be cleanable.Sept. 4, 2020
Written infection control and reprocessing policies and procedures were incomplete.Infection control and reprocessing policies that are based on current best practices are available, reviewed and updated on a routine basis.Sept. 4, 2020
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.Sept. 4, 2020
Clean medical supplies stored under sinks.Clean medical supplies not to be stored under sinks.July 2, 2020
An approved process was not followed for sterilization of reusable equipment. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.Clean and sterilize medical equipment appropriately.June 26, 2020
The sterilizer not tested with a biological indicator each day the sterilizer is used. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.The sterilizer to be tested with a biological indicator each day the sterilizer is used.June 26, 2020
Type 5 integrators were not used appropriately to justify the release of routine loads. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.Type 5 integrators to be placed in each package undergoing sterilization.June 26, 2020
Medical equipment placed in locked and unopened position in packages for sterilization. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.All medical equipment to be placed in unlocked and opened position in packages for sterilization.June 26, 2020
Medical equipment packages were overloaded for sterilization. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.Package medical equipment for sterilization to allow steam to move around and through the items and all contact surfaces.June 26, 2020
Sterilized packages not the correct size and not labelled. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.Sterilized packages to be based on the size and weight of the medical equipment and labelled with date processed, cycle or load number and the health care provider’s initials. June 26, 2020
The manufacturer’s instructions for use of packaging medical equipment was not followed. ORDER has been issued to ensure compliance. As of June 26, 2020, all contents of the order have been satisfied.Follow the manufacturer’s instructions for use when packaging medical equipment.June 26, 2020
Reprocessing area is not a separate area with sufficient counters and space to follow a one-way work flow.Reprocessing area is to be a separate area with sufficient counters and space to follow a one-way work flow from dirty to clean.June 26, 2020
A log of test results, parameters and maintenance during sterilization not kept.Record and maintain appropriate results on log sheet.June 26, 2020
Cleaning brush for reprocessing was worn and was not discarded.Cleaning brush for reprocessing to be cleaned, disinfected, dried and stored after each use, or discarded.June 26, 2020
Hand sanitizer containers refilled/topped up.Hand sanitizer containers not to be refilled/topped up.June 26, 2020
Hazardous products not properly labelled according to The Workplace Hazardous Materials Information System requirements.Label all hazardous products according to The Workplace Hazardous Materials Information System requirements.June 26, 2020
Opened multi-dose medication vials not labelled with date opened.Multi-dose medication vials are to be labelled with date opened.June 12, 2020
Unopened medication vials not discarded as per expiry date.Unopened medication vials are to be discarded as per manufacturer expiry date.June 12, 2020
Cold chain not maintained according to guidelines.Cold chain to be maintained according to guidelines. June 12, 2020
Expired vaccines not discarded according to manufacturer’s expiry date. Discard expired vaccines according to manufacturer’s expiry date.June 12, 2020

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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