Initial complaint received on October 25, 2017. A second complaint was received on 2018-06-19 regarding the cleaning and disinfecting of clinical instruments.
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 October 25, 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 October 31, 2017.
|Pouches were overlapping on the sterilizer tray.||Pouches are to be placed on the tray without overlapping as according to manufacturers’ instructions.||July 11, 2018|
|Observed used nail clippers left on top of clinic counter after patient care.||Medical equipment/devices to be kept moist in a labeled transport container if cleaning cannot be done immediately.||July 11, 2018|
|Written policy and procedures were not fully available for infection prevention and control practices and reprocessing.||Ensure that policy and procedures related to infection prevention and control and reprocessing are available, reviewed, and updated on a regular basis.||July 12, 2018|
|Biological indicators previously running in the morning, however, the schedule for BI was changed to the end of day.||The biological indicator shall be placed in the first load of each day the sterilizer is used.||July 11, 2018|
|Disinfectants and Alcohol based hand rubs were observed past expiry date.||Disinfectants and Alcohol based hand rubs are not used past expiry date.||July 11, 2018|
|Education and training related to infection prevention and control and re-processing of medical equipment/devices/instruments were not reported and documented.||Ensure that all education and training related to infection prevention and control and re-processing are reported, documented, and maintained on a regular basis. Ensure staff assigned to re-processing complete appropriate training.||Nov. 15, 2017|
|Proper functioning of sterilizer was not verified using indicators (physical, chemical and biological).||Ensure that the sterilizer is tested with all required indicators when the sterilizer is used.||Nov. 8, 2017|
|Medical equipment was not dried (i.e. with lint-free cloth) before re-processing.||Ensure that foot care instruments are thoroughly dried before packaging.||Nov. 8, 2017|
|Full records that document all sterilization parameters have not been met.||Ensure that a detailed log is kept to verify and document that all indicators (physical, chemical and biological) have passed during sterilization.||Nov. 8, 2017|
|Instruments were not packaged according to the sterilizer manufacturer’s instructions.||Ensure instruments are packaged according to sterilizer manufacturer’s instructions (i.e. instruments are in their open/unhinged positions, do not overlap and the appropriate pouch size is used).||Nov. 8, 2017|
|Instruments which have been reprocessed cannot be differentiated from instruments which have not been reprocessed.||Ensure that reprocessed instruments can be identified.||Nov. 8, 2017|
|Appropriate infection prevention and control signs were not available at the entrance of the clinic nor the reception desk.||Ensure that signage is posted at the clinic entrance or the reception desk.||Nov. 8, 2017|
|No eyewash station in the vicinity of reprocessing area.||Operator to obtain an eyewash station and install it in the vicinity of the reprocessing area.||Nov. 7, 2017|
|No dedicated hand hygiene sink and/or alcohol-based hand rub in the reprocessing area.||Ensure that a dedicated hand hygiene sink and/or alcohol-based hand rub is provided for the reprocessing area.||Nov. 7, 2017|
|Chemical products used for disinfection/sterilization were used beyond their expiration date.||Ensure to follow the manufacturer’s instructions; chemical products are not to be used beyond their expiration date.||Nov. 7, 2017|
|The 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.||Nov. 7, 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.