- No quality assurance procedures in place
- Failure to monitor a patient’s vital signs and document administration of narcotics
- Failure to provide women with confidential counseling
- Failure to maintain a sanitary environment, not following disinfectant instructions for vaginal probe
- Failure to ensure doctors had a current TB test
- Failure to ensure policy for the mandated reporting of carnal knowledge, incest, and rape of minors seeking an abortion. Staff admitted it was their policy to not ask any questions about the father, even if the patient was a minor.
- Expired medications found in the emergency crash cart
- No health screening provided on some employees
- Ultrasound table had 9 tears in the covering
- Clinic failed to report suspected sexual abuse of a 15-year-old who came in for an abortion
- Staff failed to obtained parental consent for a 16-year-old minor who came in for an abortion
- Failed to administer conscious sedation anesthesia according to standard. The staff did not use an aseptic technique to prevent contamination and infection risk. No documentation in the patient’s chart of name, time, route, dose, and rate of administration. NO vitals documented while the patient was under conscious sedation. – Failed to document the start and end time of abortions.
- Charts stated patients received “twilight” or “sedation” but there is no record of the administration route, dose or rate.
- Documents containing patients information were found in the dumpster in the back of the facility
- Expired supplies in use
- The prescription pad was found with pre-written scripts and doctors signature but no patient name on the prescription.
- There was not a supply of emergency medical equipment or medications in the facility. This is the medical director’s responsibility. This deficient practice resulted in an immediate jeopardy situation. This affected a patient who experienced a complication in the facility. The patient had a history of 5 previous c-sections and one miscarriage with heavy bleeding post-op. The patient experienced excessive blood loss after abortion procedure and there were no IV fluids available to administer to the patient. Also, the medications on the crash cart were expired. An ambulance was called and the patient was transported to the emergency room. A copy of the facility’s policy for restocking IV fluids was requested three times but none was provided.
- The hospital report was requested by DHS and the patient was admitted and had a surgery to remove retained products of conception. The abortion on her 15 week fetus was incomplete. The surgeon determined that the patient suffered from placenta accreta. Placenta accreta is a serious pregnancy condition that occurs when the placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This can cause severe blood loss after delivery. Ultrasound is critical for diagnosis. The complication was so severe that the patient had a total hysterectomy and bilateral salpingectomy (removal of the fallopian tubes).