In 17 of 18 charts reviewed, the physician overdosed the patients on Fentanyl. Maximum does is 1 mcg/kg. All patients were given 100 mcg but weighed under 100 kg. It was noted in the Department of Health review that the facility failed to follow the procedure in place for anesthesia administration. 

Another patient’s oxygen saturation dropped to 76% during procedure yet she was not given oxygen. There was no documentation in her medical record of intervention.

Counseling was not completed per policy on 100% of patients regarding RH negative (Rhogam injection needed) and post procedure hygiene, which is required for Chemical Abortion patients.

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Staff did not have CPR certification at time of inspection.

Vital signs were not recorded in recovery for patients who had received sedation.

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In the 2018-2019 Health Report, it was noted that:

• The state license was not visibly posted 
• Patients’ Medical Records did not contain proper informed consent records
• The clinic management failed to conduct annual evaluation of some employees 
• Repeat violation: Staff was not CPR certified 
• Quality Control Procedures were not followed to ensure ultrasound equipment was being disinfected properly 
•  There were discrepancies on the narcotics log 
• An unsecured oxygen tank was stored in the hallway next to a crash cart, creating a potential hazard 
• Repeat violation: The Infection Control Committee did not hold quarterly meetings 
• The clinic staff did not change disinfection solution after the manufacturer’s recommended time 
• The management failed to have a written fire control plan and conduct fire drills

Read the 2018 Report Here

Read the 2019 Report Here

In 2019, the Clinic for Women failed to properly clean and sanitize equipment (intracavity vaginal ultrasound probe) used from woman to woman. They were also cited for storing and using expired medications on women.

A 15 year old patient came for an abortion and the staff failed to report the possible abuse of a minor, mandatory Minor Sexual Contact Report.

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• Staff did not know proper procedure to sterilize instruments that are used from woman to woman.
• The designated infection control officer was not qualified by training or experience to serve in this role. This facility's infection control policy was substandard.
• The staff did not separate clean linen from dirty linen.
• The scrub area where the abortionist is supposed to wash his/her hands between procedures is in the instrument processing area where there may be abortion instruments soaking in the sink.
• The facility failed to decontaminate equipment that is soiled with blood between patients. The abortionist was cleaning the tubing between patients by sucking up water through the tubing, rather than sterilizing it or using new tubing.
• Expired medications were in use.
• The facility's policies and procedures did not address all aspects of patient/staff care and safety.

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Within 2018-2019, the facility failed numerous health and safety protocols, putting women's lives in danger:

• The facility's Quality Assurance program did not include a response protocol to patient emergencies.
• Repeat violation: The facility staff did not maintain accurate and complete Medical Records of multiple patients.
• Repeat Violation: Failed to maintain a health record on the staff. This put all patients and staff at risk and exhibits a disregard for the welfare of patients and staff.
• Sterile medical supplies were stored in areas that could not be properly cleaned.
• The facility stocked needles that had expired in 2001.
• Repeat violation: The staff did not properly sterilize instruments used from woman to woman.
• Repeat violation: An exam room had expired medication inside a box marked “needles,” taped shut with blue paper tape.
• There were no eye-washing stations in areas where employees were handling dangerous chemicals, which is an OSHA violation.
• The facility had a broken plug receptacle (fire hazard).
• An alcohol-based hand sanitizer was mounted directly above an electrical outlet (fire hazard).
• Repeat violation: The staff lacked documentation of TB testing, putting patients at risk of exposure.
• The heating pads used during care were not properly cleaned.
• Food was stored in patient care areas.
• Repeat violation: The staff did not properly wash soiled linens.
• Repeat violation: The facility management failed to maintain a Quality Assurance program to ensure responsible patient care and emergency protocols.
• The facility management failed to evaluate multiple employees’ job performances as mandated by law.

Read the 2018 Report Here

Read the 2019 Report Here