Women’s Center of Michigan (formerly Womancare of Southfield & Women’s Center of Southfield))

Clinic is closed

• The clinic does not meet ADA standards to accommodate the mobility challenged patients;
• No area for proper hand hygiene in the prep/recovery ward;
• Several rips and tears in the operating table pad rendering it unable to be cleaned and sanitized/ body fluids can be transferred between patients;
• The window in the instrument cleaning room was opened by staff because the air conditioner was not in use. This allowed for contaminants to enter the sterilization area;
• No emergency pull cords available in the restroom;
• Improper handling of medications (not dated when opened, controlled substances not stored in a locked cabinet, no narcotic count available);
• Clinic manager states that no standard protocol/ policy/ or procedure was written for medication storage and delivery;
• Recovery room has 7 recliners and 3 stretchers which is not enough to hold the projected patient load as staff states a surgical case can be completed in 5 minutes and the required recovery time is 3 hours;
• Expired supplies as old as four years in use; Medications were given without a physician’s order.
• The doctor failed to inform the patient of the risks of the second-trimester procedure and instead told her it was a “simple procedure”
• The patient received no counseling and no discussion of informed consent
• No RN was present and no vitals were taken during her procedure
• No documentation found regarding pills except listing them on the Anesthesia record.
• Report states Dr. Sharpe stated that he believed the upper portion of the fetus head was still attached when EMS arrived
• The facility failed to have a transfer log with follow up.
• Lack of documentation, failure to monitor, necessity of provision of care by an RN, and
  establishing a quality program to review and prevent cases like this was all discussed.
• As of the time of this survey, no such program was established
• On 6/17/14 Dr. Sharpe was found doing a 2nd-trimester procedure at the center without an RN on site and no staff with the patient in PACU.
• When the surveyor arrived, the reception desk was not staffed. The surveyor called a phone number that was on a business card for the doctor on the counter. The medical assistant answered and stated all of the staff was in the back doing a procedure
• There was no RN in the building
• The patient was left unattended
• This is the third visit where the facility has been non-compliant
• The doctor did not perform hand hygiene
• There was no vaginal prep done before the procedure
• The doctor did not inspect the products of conception to ensure the entire fetus was removed from the woman’s uterus
• No hand hygiene performed by the medical assistant
• At end of the procedure, the Medical Assistant used a common bucket that was kept in the operating room containing tap water to suck fluid through the bloody used suction aspiration tubing from the procedure. Staff confirmed the bucket contained no disinfectant, and the bucket was being used for multiple patients.
• Dr. Kalo was observed handling the bloody used suction tip and tubing in the instrument cleaning sink without gloves
• The physician did not get a signature on consent forms, had no oral discussion with the patient about consent, complications, risks.
• The physician did not give the patient the opportunity to view the active ultrasound image
• Failure to offer and provide beverages and light nourishments to patients
• The facility had dirt and grime buildup on the floors and cabinets 
• Facility failed to properly store oxygen tanks posing a hazard to all patients and staff