Each medical facility shall have readily available equipment and drugs necessary for resuscitation. If local anesthesia is utilized to perform an abortion in a medical facility during the first trimester, then the following equipment shall be ready to use for resuscitative purposes:
(i) Suction Source
(ii) Oxygen Source
(iii) Assorted size oral airways and endotracheal tubes
(iv) Laryngoscope
(v) Bag and mask and bag and endotracheal tube attachments for assisted ventilation
(vi) Intravenous fluids including blood volume expanders
(vii) Intravenous catheters and cut-down instrument tray
(viii) Emergency drugs for shock and metabolic imbalance
(ix) An individual to monitor respiratory rate, blood pressure and heart rate.
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Observations:
Based on observation and interview with staff (EMP), it was determined that Planned Parenthood Keystone-Allentown failed to have emergency oxygen readily available for resuscitation purposes.
Findings:
A tour of the facility conducted on April 26, 2024 revealed a crash cart observed to be in the hallway outside of the Recovery Room. An inspection of the crash cart revealed an empty oxygen tank.
Further observation revealed the crash cart was checked by staff on April 3, 2024.
Review of facility policy "Emergency Supplies" effective August 7, 2019 on April 26, 2024 did not address oxygen checks.
An interview with EMP1 on April 26, 2024, at approximately 1:00 PM, confirmed the above findings.
| | Plan of Correction - To be completed: 06/15/2024
Immediate Action: Back up tank was checked and replaced inoperable tank. Inoperable tank was replaced on 5.2.2024. Invoice available for review.
Systemic Changes/Measures:
The policy entitled "Emergency Supplies" will be revised to provide instruction on how physically check the tanks and immediately report issues to the center's leadership for immediate remediation. In addition, instructions will be added to replace an inoperable tank with the back-up tank when needed.
After a report of an inoperable tank is made, the Center Manager will contact vendor for immediate service.
Training on updated action steps will be completed by 6.7.2024
Monitoring Process:
The Center Manager will provide oversight by monitoring the check has taken place and confirm there are no issues with tanks. Oversight of this process will be documented on the "Daily Weekly Monthly" form.
The Director of RQM will request documentation/confirmation tank(s) are operable monthly until 100% compliance is achieved
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