Eye surgery facilities in Bridgeport and Waterford have been fined for performing surgery in the wrong eyes of patients, neglecting to notify the patients of the error and failing to report the mistake to state authorities.
Constitution Eye Surgery Center East in Waterford was fined $2,500 and the Robbins Eye Center in Bridgeport was fined $2,000, according to reports by the state Department of Public Health.
At Constitution eye center, where Dr. Robert Klimeck is president, two patients out of the 22 patients whose records were reviewed had surgery performed in the wrong eyes in 2010, according to the Nov. 29, DPH report.
In the first patient case, the Constitution eye center failed to tell the patient or the patient’s family that the doctor selected and implanted the wrong lens, and the facility failed to report this mistake to the state as required. The error was discovered while the patient was in surgery and corrected during surgery. In the second case, another patient had surgery performed in the wrong eye and was never told, nor was this reported to the state.
Also at Constitution eye center, after three people on the medical team noted in the patient’s records that the patient was allergic to Versed, a nurse administered Versed intravenously during the operation. The documentation did not reflect the patient’s response to this medical error, nor was there any evidence that the provider notified the patient or the patient’s family that the patient was given medicine he or she was allergic to.
Inspectors found more than a dozen violations of record-keeping regulations, the report says. For 18 of the 22 surgery patients whose records were reviewed, the facility failed to ensure that the records were accurate and complete. For three of the four patients who had laser surgery, the clinical records were incomplete.
In addition, even though one patient having eye surgery did not give consent, a salesman was present during the surgery, a violation of the patient’s rights.
The state ordered Constitution center to submit a plan of correction for each violation.
At Robbins Eye Center, where Dr. Kim P. Robbins is president, a doctor performed cataract surgery on a patient’s right eye in March 2009 when the patient was scheduled to have the surgery on the left eye, according to the Oct. 31 consent order. During a conversation with an inspector, the facility’s doctor said the incident was not reported to the state because the facility planned to perform the surgery on both eyes anyway.
There was no sign that staff investigated how this error occurred or that procedures were implemented to prevent a recurrence of operating on the wrong eye, the DPH report says.
The center was cited for inadequate sanitation in the operating room. Twice, the inspector observed medical staff opening sterile packages for the next operation, while other staff members were still in the operating room wiping down surfaces and cleaning up from the prior surgery. The Robbins center’s infection control procedure guidelines had not been updated since 2007, and the facility lacked a qualified infection control nurse or comprehensive infection control program.
“The facility failed to provide a functional and sanitary environment for surgery,” the report says.
At Robbins center, the level of medical follow-up and monitoring after surgery was inadequate, the report says. Four surgical patients were not evaluated by an anesthesiologist prior to discharge, and 10 of the 26 surgical patients whose records were reviewed had not been assessed following surgery by a registered nurse.
The report raised several concerns about the staffing, saying the facility lacked evidence that medical staff had the necessary credentials for their jobs. For example, the facility did not have on file the credentials of six anesthesiologists contracted to work there. The person hired as the “Post Anesthesia Care Unit Manager” is not a licensed nurse and lacked documentation of any previous experience working in a surgical facility, according to the report. There was no evidence that several registered nurses and licensed practical nurses received an orientation of the facility when they were hired or received annual performance reviews.
The Robbins center must submit corrective action plans for the violations that were noted in the DPH report. The center hired a private consultant, who will submit an assessment to DPH on “the licensee’s ability to implement and maintain quality care and services.’’