Re-processing area did not meet best practices for work flow and storage to prevent cross-contamination. High-level disinfectant used for equipment cleaning was past its manufacturers stated expiry date.
Diseases resulting from similar errors in infection control may include:
Public Health Nurse
Public Health Nurse
905-980-6000 ext. 7330, toll free 1-888-505-6074
A complaint was identified from a member of the public on August 1, 2017, related to infection prevention and control concerns.
This infection prevention and control lapse involved a member of the regulatory college.
An initial onsite investigation was conducted on August 2, 2017.
|Written policies and procedures were not available for infection prevention and control practices.||Ensure that written comprehensive policies and procedures related to infection prevention and control are based on the most current best practices available, are reviewed, and updated on a regular basis.||Nov. 2, 2017|
|Test strips were not being used to check for efficacy of the high-level disinfectant.||Ensure that test strips are available for testing the high-level disinfectant.||Sept. 12, 2017|
|Ultrasonic washer was not tested for efficacy at least weekly or according to manufacturer's recommendations.||Ensure that the ultrasonic washer is tested at least weekly.||Sept. 12, 2017|
|There was no evidence of on-going preventative maintenance for the ultrasonic washer.||Ensure ultrasonic washer receives regular preventative maintenance.||Sept. 12, 2017|
|Education and training related to infection, prevention and control were not reported and documented.||Ensure that all education and training related to infection, prevention and control are reported, documented, and maintained on a regular basis.||Sept. 12, 2017|
|Re-processing area did not meet best practices for work flow and storage to prevent cross-contamination.||Ensure that the re-processing area meets best practices for work flow and storage (i.e., dirty to clean).||Aug. 15, 2017|
|High-level disinfectant used for equipment cleaning was past its manufacturers stated expiry date.||Discard solutions on or before expiry date.||Aug. 15, 2017|
|Equipment not totally submerged in disinfectant.||Ensure that equipment is totally submerged in disinfectant.||Aug. 15, 2017|
|The integrity of the stored sterilized packages displayed evidence of contamination (i.e., Watermarks).||Ensure that the integrity of the package is inspected after sterilization.||Aug. 15, 2017|
|Sterilizer was not tested with a biological indicator each day the sterilizer was used.||Ensure that a biological indicator is used to test the sterilizer on a daily basis.||Aug. 15, 2017|
|Records were not kept to document that all sterilization parameters have been met (e.g. time/temperature/pressure readings).||Ensure that records are kept to document that all sterilization parameters have been met (e.g. time/temperature/pressure readings).||Aug. 15, 2017|
|Sterile items were not stored in their sterile packaging until time of use.||Ensure that sterile items are stored in their packages until time of use.||Aug. 15, 2017|
|Soiled equipment was not kept moist prior to cleaning.||Ensure that equipment is kept moist if cleaning cannot be completed immediately.||Aug. 15, 2017|
|Equipment was not adequately dried prior to high-level disinfection or sterilization.||Ensure that equipment is air-dried or a lint-free cloth is used for drying of equipment prior to high-level disinfection or sterilization.||Aug. 15, 2017|
|Records were not kept to document that all high level disinfectant parameters had been met, nor which equipment re-processed in the disinfectant.||Ensure that records are kept to document the use of high level disinfectants as per manufacturer’s instructions, as well as documentation of the staff member responsible for re-processing.||Aug. 15, 2017|
|Equipment was not rinsed with water after high-level disinfection.||Ensure that all equipment is rinsed with water after high-level disinfection.||Aug. 15, 2017|
|Items were not packaged according to the manufacturer's instructions.||Ensure that equipment loaded into sterilization packages are loaded without overlapping or touching in the packaging.||Aug. 15, 2017|
|Alcohol based hand rub was expired.||Ensure that the alcohol based hand rub is on or before expiry date.||Aug. 15, 2017|
|Personal Protective Equipment (PPE) was not available at point of care or in the re-processing area (i.e., gowns, eye protection).||Ensure that PPE is available at point of care and in the re-processing area. Ensure that PPE is worn as per best practices.||Aug. 15, 2017|
|Chair in the clinic room was observed to be cloth, not smooth, non-porous, seamless and cleanable.||Ensure that all furniture is smooth, non-porous, seamless and cleanable.||Aug. 15, 2017|
|Appropriate infection prevention and control signage was not available at the entrance of the clinic nor at the reception desk.||Ensure that signage is posted at the clinic entrance or at the reception desk.||Aug. 15, 2017|
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.