A mother’s death a day after childbirth, a patient’s brain injury and death following thyroid gland surgery, a child’s abduction, and a sexual assault involving two patients were among the incidents cited in the latest round of hospital inspection reports conducted by the state Department of Public Health (DPH).
The 36 new reports, which can be found in C-HIT’s Data Mine section, cover state inspections that took place at hospitals between 2017 and earlier this year. There were several instances when objects were left in patients following surgery.
At Manchester Memorial Hospital, a series of staff errors contributed to a woman’s death one day after giving birth to a stillborn baby, the DPH inspection report said. The patient delivered the baby Jan. 18, 2018, and staff failed to deploy a rapid response team as her condition worsened when she developed an infection and suffered septic shock. The hospital also failed to have a doctor present for a high-risk pregnancy instead of a certified midwife.
Check out our hospital inspection reports database, where you can see the latest state inspection reports here.
An investigation found that the woman went too long before undergoing an emergency cesarean section, and that the hospital failed to ensure that a vaginal balloon catheter, used to induce labor, was removed after 12 hours to reduce the risk of infection. The hospital also failed to have clear guidelines for on-call providers related to high-risk pregnancies. The woman was airlifted Jan. 19, 2018, to another hospital, where she went into cardiac arrest and died that day.
At The Hospital of Central Connecticut in New Britain, a patient died after suffering a severe brain injury, the report said. A patient had a thyroidectomy on Jan. 9. During surgery an endotracheal tube was placed incorrectly and there was a delay in calling an anesthesiologist, who should have been in the room when the patient was extubated. Staff also failed to use an overhead paging system when the patient went into cardiac arrest following the surgery. The patient subsequently suffered a severe brain injury and died Jan. 19, state inspectors reported.
At Lawrence + Memorial Hospital in New London, a 3-year-old child was abducted by an unauthorized person and a non-custodial parent on April 12, 2018. An inspection found staff failed to protect the child in a high-risk situation and failed to initiate an abduction response plan in a timely fashion.
Also, at L+M staff failed to ensure a patient had nothing to eat or drink prior to a Nov. 9, 2017, colonoscopy. A certified registered nurse anesthetist gave the patient coffee before the procedure, which records didn’t show, and the patient vomited during the procedure. The patient, who subsequently developed pneumonia and renal failure, died on Nov. 28, 2017.
A sexual assault involving two patients occurred at Middlesex Hospital in Middletown on Nov. 8, 2018, according to the report. Video surveillance from 4:38 to 4:44 p.m. showed the two patients sitting in a common area at a table, drawing pictures and touching each other’s private areas. One of the patients went into a room and the second patient, who was supposed to be checked by staff every 15 minutes, followed and closed the door. An investigation found that the facility failed to follow policy on patient rights, which states that patients have the right to safe care at all times.
Yale New Haven Hospital was cited for various violations, including two cases in which patients were burned. On Oct. 20, 2017, a patient receiving a root canal in the dental department suffered a chemical burn to the gum after a tooth was perforated during a sterilization process. On April 3, 2017, thermal grounding pads used to warm a patient during a liver ablation and biopsy overheated and the patient suffered a skin tear on the left thigh and skin blister on the right thigh.
Also, at Yale New Haven a patient who underwent a robotic hysterectomy on March 4, 2018, had 6 to 8 inches of plastic tube protruding from her genitalia after the procedure. In a separate case, in May 2017, staff failed to remove an atrial pace wire prior to discharging a patient who had cardiac catheterization.
Bridgeport Hospital was sanctioned and fined $150,000 after erroneously switching eight patient specimens, which resulted in two patients being given the wrong cancer diagnosis.
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.
To view the hospital inspection reports click here.
C-HIT writer Kate Farrish and C-HIT Assistant Editor Bonnie Phillips contributed to this report.