Summary of Deficiencies at Delta Clinic of Baton Rouge
Date of Report: 7/13/2018
READ FULL REPORT Delta July 2018: Department of Health
Document Length: 51 pages
Clinic: Delta Clinic of Baton Rouge
Address: 756 Colonial Drive, Baton Rouge, LA 70806
Review of Delta Clinic found the following deficiencies:
- INADEQUATE STAFFING: Delta failed to ensure that the abortion facility is equipped with the staff needed to help patients as required by the Louisiana State Board of Nursing Administrative Rules Defining RN Practice (LAC 48:XLVII).
- In interviews dated 7/11/18 and 7/13/2018, an LPN, the Medical Director and the Director of Nursing complained that the facility is not adequately staffed (pg. 2). The physician also asked for a nurse in the exam room during procedures, but the facilities nurse’s were needed in patient recovery.
- After being presented with a hiring package for better staffing, the President of Delta declined it because “it was too expensive.” They continued with the current staff and scheduled 10-12 procedures per day (pg. 4).
- INCORRECT, INCOMPLETE PATIENT RECORDS: The Registered Nurse failed to ensure that nursing services were in line with the Louisiana State Board of Nursing’s requirement for proper documentation of medications and correct drug administration.
- Six out of Fifteen patient records found incorrect documentation regarding a physician’s drug order in March and April of 2018 (dates: 3/22,3/29,4/17,4/26,4/27) (pgs 7-12).
- Interviews between April 2018-July 2018 showed that required forms, Surgical Abortion Stand Order, were incomplete, not timed and didn’t include patient specific information. Some medications had incorrect dosages or did not include dosages at all (pgs 43-50).
- Some patient records included no written documentation regarding drugs used during abortion procedures in March and April of 2018 (pgs 43-50).
- FAULTY PERSONNEL RECORDS, PERSONNEL EVALUATIONS: Delta employees failed to have up-to-date personnel records regarding the training of its staff as required by the Louisiana Administrative Code (LAC 48:I section 4423, 4427).
- Interviews in July 2018 revealed that Delta lacked current annual evaluations for competency of their medical assistant, scrub tech, sonographer, director (pgs. 17-21).
- LATE REPORTING: Delta did not meet the standards of Louisiana Revised Statute 40:1061.21 regarding abortion reporting by submitting the Induced Termination of Pregnancy (ITOP) report late (pgs. 29-31).
- SUBSTANDARD HANDLING OF MEDICATION: Tour of Delta in July 2018 revealed that six syringes filled with Lidocaine and Epinephrine were left from the following procedure day, which occurred two days prior (pgs 32-24).
- Interview dated July 11th 2018 with staff includes admissions to failing to labeling or dating medication properly as required by the Louisiana Board of Pharmacy and Drug Enforcement Agency (DEA) (pgs 35-38).