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• D.Elam,MD KAISER PERMAN L Wes ician-in-Chief RECOWE e win N.Harper,MHA,FACHE March 1,2010 for Vice President/Area Manager 11 4 Z�j Q Central Valley Service Area Derek LaMont Public Works Department/Engineering ENIVIRUNIu ENT HFFLTH City of Manteca PERN111TI,%QjLPV3CE j 1001 W. Center St. Manteca, CA 95337 Dear Mr.LaMont, The purpose of this letter is in response to your request for documentation of the potential discharge of approximately 6 gallons of un-neutralized gluteraldehyde into the drainage system at the Kaiser Permanente Manteca Medical Center during the time frame of February 12-February 16, 2010. On Friday evening, February 12, 2010, the Sterile Processing Technician set the ultrasonic scope processing washing machine for a normal wash cycle with 8 gallons of un-neutralized gluteraldehyde. During the wash cycle, the machine had an error and would not advance to the fill cycle. The machine was turned off and restarted. A second attempt to complete the cycle was made and was unsuccessful. The machine was turned off for the night. On Saturday, February 13, 2010, the Technician returned to complete the cycle from the night prior. Again, the machine would not advance to the fill cycle. The machine was turned off and was noted to contain 8 gallons of un-neutralized gluteraldehyde. On Tuesday, February 16, 2010, the Sterile Processing Manager arrived to discover approximately 6 gallons of gluteraldehyde was missing from the machine. I was notified that morning and conducted and internal investigation of the situation. The vendor was contacted to perform testing on the machine and determine if a malfunction had occurred. The vendor concluded that based on tests performed that day, no machine malfunctions were noted. Upon completion of my investigation, I was unable to conclude when and where the gluteraldehyde went. I have made recommendations to the department to provide education to all staff on the scope processing machine to prevent this from occurring in the future. Kaiser Permanente is dedicated to abiding by all applicable regulatory requirements. If you require any additional information please contact me at the below listed number. Respectfully, Yf,M 6U%taAAj Tonia Shaw Safety Coordinator Environmental Health and Safety Kaiser Permanente Central Valley Area (209) 825-3885 1777 W. Yosemite Ave. Manteca, CA 95337 Cc: Robert McClellon,Program Coordinator for Environmental Health Department, San Joaquin County Darryl B. Curry,AR&L Director Sue Preston, Compliance Officer Stockton Medical Office Manteca Medical Center Tracy Medical Offices Modesto Medical Offices 7373 West Lane,Stockton,CA 95210 1777 W.Yosemite Avenue,Manteca,CA 95337 2185 W.Grant Line Road,Tracy,CA 95377 Post Office Box 577680,Modesto,CA 95357