Falls Church Health Care Center

Policy and procedure manual had not been reviewed or updated in 2 years
The facility changed administrators and did not notify the state
There was no verification of professional license and certification on 3 employees and the administrator stated that they were “not aware this was required”.
No personnel policies and procedures are in place to monitor performance and competency
Patients not given a copy of their rights and responsibilities upon admission as required by the state
Patients were not given a copy of the complaint procedure as required by the state (repeat violation 2014, 2018)
Linens were not washed and handled properly to prevent the spread of infection and contamination
Staff failed to maintain a safe and sanitary environment in the procedure room
Failure to maintain health records of immunizations and screenings on the employees. This shows a lack of concern for the health and well being of the staff and the patients.
Failure to maintain equipment and supplies – tears in the vinyl on exam tables, no cover on the oxygen mask, expired supplies, catheter out in the open and not bagged
None of the staff, anesthesia providers, or physicians had completed infection control training.
Staff did not use the aseptic technique to administer medications.
Staff did not clean re-usable equipment between patients.
Staff used tap water from the hand washing sink to clean the vacuum line from the suction machine after a procedure.
Staff administered misoprostol (Cytotec) to a patient before the physician saw her and determined if he would perform the procedure. The physician decided to refer her to another facility because her sonogram showed she was over the 13 weeks and 6 days limit. Misoprostol (Cytotec) is not indicated to be used past 8 weeks. According to the package insert: UTERINE RUPTURE HAS BEEN REPORTED WHEN CYTOTEC WAS ADMINISTERED IN PREGNANT WOMEN TO INDUCE LABOR OR TO INDUCE ABORTION BEYOND THE EIGHTH WEEK OF PREGNANCY…”.
Staff failed to adhere to infection control policy.
- Staff member used a single dose vial for multiple patients. The facility did not have a policy, procedure or nationally recognized best practice standard, which allowed for using single dose vials as multi-dose vials.
- Staff member used a single use inhaler for more than one patient.
- Staff member used the procedure table to draw up medications.
Expired medications were in use – some as old as 3 years. Staff Member #1 stated, “We follow a no expiration policy.” Staff Member #1 reported the facility had documentation that expiration date did not matter.
The facility staff and physicians failed to ensure patient’s medical records were complete and accurate, including progress notes, the doses of administered medications, the authentication of signatures and administration of medications with dates and/or times, discharge orders and patient consents/notifications for 100% of the charts reviewed.
It was determined the facility failed to report a serious injury to a patient to Office of Licensure and Certification (OLC). A patient had a surgical abortion in Feb 2018 and was transferred to the hospital for excessive blood loss. She had a perforated uterus. According to policy, this was to be reported to OLC within 24 hours. It was never reported. The facility administrator advised the clinic did not contact the Office of Licensure and Certification (OLC) because they believed they were not required to. He/she further explained the facility has had patients transferred out in the past but the clinic did not notify OLC during those events either.

Report 2014 Report 2016 Report 2018

DISCLAIMER: All of the inspection reports on this site were acquired through public records request to state departments of health and public records online.