Northeast Ohio Women’s Center

• All 5 nurses had not received orientation training;
• The clinic had no director of nursing at the time of inspection;
• Expired medications and supplies being used.

2016

• The facility failed to evaluate the quality assurance and performance improvement plan annually. There was no quality improvement policy, program, or committee in place. There was no one designated to oversee the quality assurance plan.
• The facility failed to develop comprehensive patient care policies which included patient’s treatment, patient’s right to refuse or withdraw consent for treatment, access to medical records, maintaining medical and financial information for patients in a confidential manner, detailing an explanation of charges for medical services to patients.
• The facility failed to follow its own infection control policy. Six staff members did not have a current TB skin test. This had the potential to affect all patients and staff in the facility.
• The facility had no infection control program or officer.
• There were no job descriptions for the employees at this facility.
• There was no evidence of an ongoing training program for staff.
• There was no evidence of OSHA/blood borne pathogens training for staff.
• There was no evidence of counseling/communication training for staff.
• There was no evidence of training or orientation for 3 of the 7 staff members of facility equipment or safety policies and protocols.
• The facility failed to perform annual performance violations.
• The staff did not sterilize instruments properly that are used from woman to woman.
• The freezer used to store products of conception had no temperature log.
• There were expired medications and supplies available for use on patients and staff.
• The was no evidence in the personnel file that the Director of Nursing was qualified for the position. There was no evidence that the reference checks were completed on the staff member.
• The facility failed to ensure that two nurses were present and on duty at all times in the facility on treatment days.
• The licenses of 3 RNs that were on file were expired in August 2015. There was no evidence to reveal that the licenses were checked to ensure they were current and without disciplinary action.

2017

• There was no quality assurance plan or manual in place. There were no regular meetings to discuss the quality of patient care.
• The facility failed to ensure that 5 staff members had TB testing.
• The facility failed to ensure that a staff member had a job description.
• The facility failed to ensure that 3 RNs had Advanced Cardiac Life Support certification as required by the facility’s own policy.
• One staff member did not receive training on the re-processing of instruments.
• One staff member did not have a performance evaluation.
• The facility failed to maintain a safe and sanitary environment. A staff member was in the sterilization room. She donned her gloves, gown and mask to process instruments. She finished and took off her mask and gown and placed it on top of two boxes that were in the room. She returned to the room and donned the same mask and gown. The inspector asked what was in the boxes and it was biohazard waste waiting for pickup.
• The metal treatment table in the surgical suite was patched with blue tape. The tape had rolled up and left the table sticky in areas.
• A roll of packing tape was on top of the freezer that contained fetal tissue. A staff member went to open the freezer and she placed the tape on the edge of the freezer. When she opened it, the tape fell into the freezer twice.
• The was no evidence in the personnel file that the Director of Nursing was qualified for the position. There was no evidence that the reference checks were completed on the staff member. (repeat violation)
• The facility failed to ensure that two nurses were present and on duty at all times in the facility on treatment days.  (repeat violation)
• There were expired medications and equipment in the emergency supply box.

2018

• The facility failed to ensure that 2 staff members had TB testing. (repeat violation)
• There were no performance evaluations done for 3 staff members
• The ultrasound table had a piece of black duct tape on it covering a tear.