Hayes assured Beverly's parents that she would be "all right" just fifteen minutes before she died.
Chattanooga Women's Clinic was written up for continued deficiencies even after Beverly's death. Noted flaws included (with dates of citation):
- "Wrist, knee or foot controls not provided on lavatories used by physicians and nurses" (3-8-79)
- No system for referring patients to other health care providers (3-8-79)
- No emergency transfer arrangements (3-8-79)
- Lack of written job descriptions (3-8-79, 10-10-89)
- Lack of documentation of staff qualifications (10-10-89)
- Inoperable emergency lighting (3-8-79, 3-12-87, 3-17-87, 4-5-93)
- Re-use of disposable curettes (3-12-87)
- Medications out-of-date (5-22-85, 3-12-87, 3-17-87, 10-10-89, 4-6-92)
- Outdated IV solution (10-10-89)
- Medications improperly stored (3-8-79, 3-12-87, 3-17-87, 6-18-87)
- Unwrapped speculums stored in examining table drawer (6-18-87)
- Used disposable curettes stored on shelf with clean supplies (6-18-87)
- Blood in procedure table (10-10-89)
- Dirty floor and equipment in lab (10-10-89)
- "[O]ut of date sterile instruments are in autoclave area" (6-18-87)
- "Sterile instruments in treatment room observed to have stains" (4-6-92)
- Patient records lacking documentation of required testing for sexually transmitted diseases (10-10-89).
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