"At the time of the survey it was apparent that the facility could not ascertain the whereabouts of the Medical Director. During the four survey days, the Medical Director was not in attendance, nor could he be contacted."
"The inadequacy of staff, the lack of medical direction and supervision, and the inappropriate role of the Nurse Practitioners demonstrate the lack of control over the facility's day to day operation."
"The facility fails to have adequate staff and equipment to provide the health services for which the facility was established. An RN was by job description the Director of Gynecology. This person made independent and unsupervised decisions concerning the insertion of Laminaria and hence admission of patients to the facility."
Eastern's "recovery room was under the supervision of an LPN"
Eastern had no organized medical staff
"[F]acility failed to retain on file applications for admission to the medical staff and professional references indicating physicians relevant medical experience."
Eastern lacked an OR log.
Failure to verify health status of new employees prior to employment
lack of documentation of admitting privileges by some medical personnel at backup hospital
lack of written criteria on laminaria insertions
Eastern had "no policies and procedures indicating that a registered nurse is responsible for assisting the physician before or after a Termination of Pregnancy procedure."
Eastern had "no policies and procedures to indicate which personnel are authorized to document information in the medical records."
lack of medical assistant training protocols
unqualified staff reviewing medical histories with patients
standing order sheet was undated and unsigned
"Counseling notes failed to adequately document patient problems and needs. Medical records do not contain evidence that patients undergoing general anesthesia have been counseled to have escort available upon discharge. Patients at times travel to cities such as Philadelphia with no note of escort on chart."
failure to administer RhoGam within 72 hours of the abortion
medications not always ordered by a physician
doses of medications were not always noted
names of medications were not always noted
incomplete or lacking documentation of adverse drug reactions
A patient was given the wrong drug
no qualified person supervising medical records department, some requested records could not be located
"Nursing assistants were writing surgical notes without counter-signature of surgeons"
Nurse Practitioners inserting Laminaria without physician written order or examination
failure to audit medical records
no follow-up documented for an abnormal lab result
Eastern performed three abortions on one patient in four months
records lacking lab results
abnormal cultures noted but not repeated
complete history and physical missing from charts
incomplete physical exams in charts
non-medical Patient Facilitator notes what procedure is to be done
no evidence of physicians appointed to oversee anesthesia, recovery, and OR
anesthesiologist supervised by nursing director
failure to appropriately screen for anemia, cervical cancer, STDs, and other factors, and lack of post-op follow-up reports
ceiling tiles were discolored, moldy, or missing
dirty IV poles in procedure room
one scavenger vent needed to be cleaned
dried blood on storage room wall
fire corridor blocked by linen cart, other fire corridors blocked with cabinets, supplies, copy machine, and supply shelves
most exit lights on 6th floor inoperative
ORs used for storage of boxes
IV tubes and solutions reused.
Source: Statement of Deficiencies July 20-24, 1987