Infant injuries, wrong-site surgeries, objects left in patients following procedures, and a health care worker hitting an “unruly” patient were among the incidents cited in hospital inspections conducted by the state Department of Public Health.
The new reports, which can be found in C-HIT’s Data Mine Section, cover state inspections that were completed in 2021 with approved hospital corrective action plans. (You can find the new reports here.)
At William Backus Hospital, a pregnant woman suffering from drug abuse disorder delivered a baby who tested positive for fentanyl and buprenorphine. During the time that the baby was under observation for neonatal abstinence syndrome (drug withdrawal), a parent holding the infant fell and reported “that the infant’s head may have touched the ground a little,” the report said. Following the incident, staff determined that the baby suffered a head injury and was transferred to a higher-level hospital. The state inspector said that the hospital “failed to develop a safe plan of care for the infant to prevent a fall with injury.”
The Hospital for Central Connecticut was cited for failing to identify that an infant was assessed when forceps were used in labor and delivery, which resulted in head injuries to the infant. During delivery, forceps were used unsuccessfully to rotate the baby’s head, so the baby was delivered by cesarean section, the report said. Hours after delivery, the infant was transferred to the neonatal intensive care unit and was later transferred to another hospital for neurosurgical evaluation.
In six instances, Hartford Hospital was cited for failing to follow surgical and invasive procedures which resulted in a wrong-site surgery and objects retained after surgery. In two of the cases, a lumpectomy was performed on the wrong area of a woman’s breast and in another a doctor failed to remove the entire gastric lap band during a removal procedure.
At Lawrence + Memorial Hospital, a nurse punched an unruly patient in the stomach and was later disciplined and suspended for a week, an inspection report said.
Hartford Hospital was also cited for not following a patient’s dysphagia diet of puree consistency. The patient was given a tuna sandwich and apple juice. The patient began to choke, a medical code was called, and the patient was revived using CPR, state records said.
MidState Medical Center was cited for not having a policy or guidance for use of a stabilization method after a photo was posted on social media, according to the state report. A child was treated in the hospital’s satellite emergency department for an injury, accompanied by a parent. The child was wrapped in a blanket on a stretcher, secured by gauze tied underneath the stretcher. The hospital was cited for not having a policy or procedure for this type of immobilization.
Several hospitals were cited for dust build-up in operating rooms and torn operating table pads.
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.
The 2021 inspection reports for the following hospitals are in C-HIT’s DataMine Section: Bridgeport, Bristol, Danbury, Griffin, Hartford, Hospital of Central Connecticut, UConn/John Dempsey, Lawrence + Memorial, Middlesex, MidState, Norwalk, Sharon, Stamford, and William Backus.