Various violations that jeopardized patient safety, including two that preceded patient deaths and several involving the improper use of restraints, have taken place at Connecticut hospitals, according to the most recent hospital inspection reports released by the state Department of Public Health (DPH).
The reports, which can be found in C-HIT’s Data Mine section, cover inspections that took place at hospitals between 2016 and this year. Some of the violations resulted in injuries to patients, while others showed lapses in protocols and procedures.
Bridgeport Hospital was cited for 26 violations, including an incident in which a patient with a diagnosis of an ovarian mass suffered a burn during surgery. Hartford Hospital was cited for 60 violations, including two violations that preceded patient deaths.
At Bridgeport Hospital, a patient suffered second-degree burns on May 22, 2017, when a surgeon used an electrical surgery device at the same time as a flammable surgical preparatory solution. The hospital was cited for several violations pertaining to the incident, including that the surgeon—who had three operations underway simultaneously—failed to let the flammable solution dry before using the device. The hospital’s corrective action plan said staff was retrained and that “no physician will be permitted to schedule simultaneous operative cases as the primary surgeon at the same time” in the OB/GYN department.
On Jan. 23, 2017, at Hartford Hospital, a patient with chronic obstructive pulmonary disease died from an air embolus, which most likely resulted from a central line. According to the report, an investigation found staff had incorrectly administered food and medication through a nutrition infusion that used the central line.
Another patient died on July 20, 2017, from mucormycosis, a serious fungal infection. Records showed that when the patient previously was discharged from the hospital following a heart transplant, staff recommended the patient go to a short-term rehabilitation facility but ultimately followed the patient’s wishes to be discharged home—even though the home was partially under construction. Construction sites can house the mucor bacteria.
In other incidents at Hartford Hospital, a patient admitted Oct. 25, 2016, for a hip replacement had to return to surgery following the procedure because a piece of broken needle was left inside the body. Separately, after another patient had robotic-assisted hip arthroplasty on Jan. 9, 2017, a second surgery was needed to remove a sponge retained in the body.
St. Mary’s Hospital in Waterbury was cited for various incidents, including delays in testing results reaching doctors and improper use of restraints.
Windham Hospital also had violations regarding restraints. In one case, a patient was put in restraints for five hours when he or she should have been reviewed after one. Another patient was put in restraints without the reason being documented.
A Norwalk Hospital patient was held in restraints for 21 hours and not released from them as soon as possible. In another instance, staff failed to assess the pain level of five patients.
At Griffin Hospital in Derby, doctor’s orders weren’t followed in the use of restraints on one patient. Also, at the hospital, a patient fell and broke a hip after being improperly restrained during transport; and an endoscope wasn’t properly cleaned using a lint-free cloth.
And, at Connecticut Children’s Medical Center in Hartford, a 13-year-old tried to escape a locked behavioral health unit in the Emergency Department and was given a medication, Haldol, and suffered an allergic reaction to the drug, the report said.
After inspection reports are sent to the hospitals, each submits a corrective action plan that requires DPH approval. The corrective action plans are included in C-HIT’s database.
Inspectors from DPH generally survey Connecticut hospitals in unannounced visits every two to four years. They tour facilities, observe staff in action and examine documents. Though hospitals are surveyed every several years, DPH usually inspects them more often in response to complaints and investigations, according to DPH spokeswoman Maura Downes.
You can view the new hospital inspection reports here.
C-HIT writer Kate Farrish and assistant editor Bonnie Phillips contributed to this report.