Clinic administrator acted as the surgical assistant on an abortion procedure but did not wear proper protective equipment to prevent splash or splatter. She wore no outer gown or eye protection as required according to the facility’s PPE policy for procedures. She handled the tubing from the suction machine and the POC (products of conception) in the glass jar. The clinic counselor cleaned the room after the procedure.

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Staff failed to clean and disinfect the procedure room between patients. Staff disregarded patient’s allergies noted in her chart as well as her allergy band and offered her a snack that contained an allergen. Staff violated HIPAA by discussing patient’s health history, birth control plans, personal and confidential information in the presence of another patient in recovery.

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The inspector observed a patient from intake to recovery. A staff member came in and administered an IV to the patient without speaking to the patient, never introduced him/herself, and did not instruct the patient on what was about to happen or the drug being administered into the port. Staff member remained completely silent. Staff went to the foot of the exam table, spread the patient’s legs and hung them over the stirrups. No drape was used leaving the patient completely exposed from the waist down. Introductions were made after medication was administered and the patient appeared to be falling asleep. The procedure was eventually completed and it was noted that the patient had been completely exposed from the waist down for 30 minutes and the doctor never introduced himself to the patient.

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Facility’s quality improvement committee did not have the required members. The committee failed to include a physician and an individual with the demonstrated ability to represent the rights and concerns of patients. The committee also failed to provide an annual report to the governing body. Finally, patients were not given a copy of their rights and responsibilities as required by the state.

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Facility had no documentation of licensure or certification for the registered nurse who administered anesthesia. One had no record of licensure and the others license was expired.

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Medical records were not stored securely. Not only that, but the facility failed to keep a complete and accurate medical record: no estimated gestational age of the fetus, no physicians signature on discharge, no signature of who performed the counseling, no record of who administered anesthesia, no progress or recovery notes, forms filled out in pencil, dates crossed out. The physician walked out of the interview with the inspector when confronted with the medical record issues.

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Facility details:

• Total revenue: $11,934,155
• Program service revenue: $6,522,926
• Facility committed an abortion on a patient without obtaining informed consent.
• Staff did not wash their hands after removing gloves before putting on new gloves according to CDC protocol and facility policy.
• Recliners in the recovery room had food particles in the crevices left over from patient’s snacks.
• The recliners were not disinfected between patients.
• NO infection control training . Staff unaware of procedure to maintain a sanitary and safe environment because they had not been trained properly in infection control.

Facility details:

• Unauthorized personnel had access to the narcotics cabinet.
• Staff failed to use safe injection practices by re-using needles to draw up medications, putting patients at risk for infection.
• A complication log revealed that a family member had called for a patient who had an infection due to an incomplete abortion. They reported to an emergency room. There was no record of this incident being reported to the state as required or documenting the infection.
• No progress notes or observations in recovery documented in patients' charts.
• No time of discharge noted.