Whole Woman’s Health of Peoria

• This facility failed to ensure that equipment was inspected and maintained to ensure safety
• No documentation of preventive maintenance done on any of the suction machines in treatment rooms
• Expired medications were in use

March 2018:

• The facility did not follow its own credentialing procedure for physicians. The credentialing committee had not reviewed the credentials for all 3 physicians performing abortions at the facility.
• The credentialing committee did not monitor the quality of the medical and surgical procedures being performed.
• The physician credentials did not have any delineation of privileges.
• The physician’s hospital privileges were expired.
• The medical director agreement was not completed.
• The facility failed to ensure that an RN was on the premises when patients were present.
• The facility failed to ensure that emergency equipment (AED) was maintained and available for patient use.
• This facility failed to properly sterilize instruments that were being used from woman to woman.
• Narcotics violations – improper use and storage of multidose medication vials of narcotics, expired meds in use, LPN stated that she didn’t know an opened vial of injectable medication needed a new expiration date once in use.
• There were 3 opened syringes in the medication box out of their sterile packaging with no indication if they had been used or not. The LPN stated she “didn’t know they couldn’t do that”.
• The facility failed to ensure that surgical procedures were being performed by qualified physicians with defined practice privileges.
• The physicians had no documented specific privileges for conscious sedation but were administering the sedation.
• The physicians had no documented specific privileges for performing and reading ultrasounds.
• The physicians had no admitting privileges to a nearby hospital as required by law.
• This facility provides telemedicine abortions. The inspector observed two telemed abortions where the staff member did not ensure the physician reviewed the patient’s medical history prior to administration of the medication abortion.
• The facility failed to ensure that the standing orders were current and accurately authenticated.