Deficiencies noted in 1987 inspection:

• "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

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