Clinic Fined, Placed On Probation, For Mishandling Ebola-Like Symptoms, Other Lapses

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A prominent Hartford health center has been fined $2,500 and placed on probation for a year for numerous lapses, including mishandling a patient with Ebola-like symptoms and failing to refer a patient to a cardiologist who later had a heart attack and died.

Community Health Services, based on Albany Avenue in the North End, must also hire an infection control consultant for at least three months who will report to the state Department of Public Health on efforts to correct numerous violations cited in letters between October 2014 and March of this year.

Board chairman Robert Harris agreed to the fine and probation when he signed a consent order with DPH on Nov. 20. Within 21 days of signing the order, Community Health Services must re-train its nursing staff in infection control, reporting diseases, disinfecting medical equipment and hand hygiene.

CEO Gregory L. Stanton said all of the state’s concerns have been addressed for nearly nine months. He described the consent order as a way for DPH to monitor improvements at the center.

“Everything has been corrected with an abundance of caution,” said Stanton.

Stanton said the center has already worked with an infection control consultant for a year.

“We have a top-shelf infection control system in place today,” he said.

In handling the patient with Ebola-like symptoms in August 2014, a physician’s assistant failed to put the person in an isolation room or send the person to a hospital in an ambulance, DPH records show. The patient had gone home and arrived at a hospital some hours later without wearing a mask even though the physician’s assistant had instructed her to do so. The physician’s assistant did call the patient repeatedly urging her to go to the hospital.

After the incident, the center drafted an Ebola policy, DPH records show.  That incident lead to a detailed review, and the center has put in place an infection control system that is “one of the best in the state,” Stanton said.

The patient who had a heart attack and died Aug. 18, 2014 had come to Community Health Services with a cough in May and pneumonia in June before having a heart attack and being placed on life support in a hospital in July, DPH records show. While the medical staff indicated the patient should be referred to a cardiologist, no such referral could be found in the center’s records, DPH inspectors wrote.

Stanton said, “it would be wrong to draw a straight line of causation” between the clinical care the patient received at Community Health Services and the person’s death months later.

Numerous other violations were discovered by DPH inspectors, including that 92 patients were at risk for cross contamination because an intra-vaginal ultrasound probe had not been properly disinfected. In November 2014, inspectors also found that three vital signs machines were soiled in the adult walk-in clinic.

In January of this year, the staff failed to ensure that a patient who was coughing up blood kept a mask on or was put in an isolation room, DPH records show.

DPH also found in the fall of 2014 that the nursing staff had not been fitted for N-95 masks to protect them from infectious diseases and did not know where they were kept in the health center.

In August of 2014, a registered nurse at the health center told DPH inspectors that he had no system for tracking infectious diseases and had done little training on how to handle infections diseases other than hand-washing training in May 2014. In September 2014, DPH inspectors found that seven clinical employees had not been tested for tuberculosis.

That fall, inspectors also wrote that the health center failed to adequately sterilize equipment in its dental, adolescent, women’s or podiatry clinics, DPH records show.

Established in 1970, Community Health Services serves nearly 19,000 patients a year.


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