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Based on record review, interviews and document review it was revealed the facility failed to ensure the physician was responsible for the medical problems developed during the hospitalization in one (1) out of thirty (30) records reviewed (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1's medical record was conducted on 08/05/19. The nursing admission physical assessment documentation stated integumentary assessment was within normal limits. On 07/18/19 the wound care nurse documented stage one (1) decubitus ulcers on both the right and left heel and a stage two (2) decubitus on the patient's buttocks. An Internal Medicine progress note on 07/18/19 states under physical examination, "Skin: No change from admission." An Internal Medicine progress note on 07/20/19 and again on 07/22/19 states under physical examination, "Skin: No change from admission." The last physical assessment on 07/23/19 documented a right hand blister, right foot abrasion, stage one (1) decubitus on both the right and left heel, a stage two (2) decubitus on the buttocks and excoriation in the groin. On the physician discharge summary dated 07/23/19 there is no documentation of any skin problems or wound care instructions.

2. An interview was conducted with the Chief Executive Officer (CEO) and the Medical Director on 08/06/19 at 2:33 p.m. Regarding the physician progress notes under physical examination, if the physician documentation states no skin issues or no changes in skin since admission, the CEO stated it was his expectation the physician has assessed the skin.

3. A review was conducted of document titled Beckley ARH Appendix I, last reviewed 11/17/16. It states in part under Article VIII. Medical Records .5 Progress Notes, "Progress notes made by the medical staff should give a pertinent chronological report of the patient's course in the hospital. Progress notes shall be legible, recorded at the time of observation and shall contain sufficient content to insure continuity of care if the patient is transferred."

4. An interview was conducted with the Chief Nursing Officer (CNO) on 08/06/19 at 1:43 p.m. She stated, "There is no additional documentation we can find that the nurses notified the physician or the physician noted the patient's (patient #1) skin breakdown. All the nurse's notes and documentation are viewable by the physician."

A. Based on record review, document review and interviews it was revealed the facility failed to follow nursing policies and procedures regarding incident reporting in one (1) out of thirty (30) patients (patient #1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

1. A review of patient #1's medical record was conducted on 08/05/19. The nursing admission physical assessment documentation stated integumentary assessment was within normal limits. On 07/16/19 the shift physical assessment documentation stated he had an unstageable ulcer on both the right and left heel and heel protectors were in place. On 07/18/19 the wound care nurse documented stage one (1) decubitus ulcers on both the right and left heel and a stage two (2) decubitus on the patient's buttocks. An Internal Medicine progress note on 07/18/19 states under physical examination, "Skin: No change from admission." An Internal Medicine progress note on 07/20/19 and again on 07/22/19 states under physical examination, "Skin: No change from admission." The last physical assessment on 07/23/19 documented a right hand blister, right foot abrasion, stage one (1) decubitus on both the right and left heel, a stage two (2) decubitus on the buttocks and excoriation in the groin. On the physician discharge summary dated 07/23/19 there is no documentation of any skin problems or wound care instructions.

2. A review was conducted of policy titled Incident Reporting, last review date 1/24/17. It states in part, Under Definitions, Incident, "An incident is defined as any occurrence which is not consistent with the usual operation of the hospital or care of a particular patient. Examples include, but are not limited to: ...impaired skin integrity, hospital acquired infections or any adverse/unanticipated patient outcome ..." Under Procedure 1. Patient Incidents "A. The health care provider involved, if you have been notified of or are witness to the incident, is responsible for completing the incident report as soon as possible after becoming aware that an incident has occurred. C. The patient's primary physician shall be contacted as soon as possible and alerted to the incident by the unit or department manager if the incident ...will impact the patient's plan of care in any manner."

3. An interview was conducted with the Clinical Nurse Manager of fourth (4th) floor on 08/06/19 at 2:00 p.m. She remembered patient #1 and stated, regarding the skin integrity issues, "I did not notify the doctor and I do not know if he knew. The nurse that assesses the patient and finds wounds should notify the physician and fill out an incident report."

4. An interview was conducted with the Chief Nursing Officer (CNO) on 08/06/19 at 1:43 p.m. She stated, "There is no additional documentation we can find that the nurses notified the physician or the physician noted the patient's (patient #1) skin breakdown. It would be an expectation the nurses would tell the attending medical doctor (MD) about the issues."

5. An interview was conducted with the Director of Performance Improvement on 08/06/19 at 9:20 a.m. She confirmed there was no incident report regarding a skin integrity issue for patient #1.


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B. Based on a tour of the unit, observations and staff interviews it was revealed the nursing staff failed to followed the infection control policy for prevention of communicable diseases. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the fourth (4th) floor medical surgical (med surg) unit was conducted on 8/5/19 at 1:50 p.m. During the tour the nursing staff donned contact precautions personal protective equipment (PPE) and entered an isolation room on the unit. The nursing staff took the computer on wheels (COW) in the isolation room to give medications. After completion of the medication pass the staff removed her PPE and proceeded to the next patient room. The nursing staff failed to properly clean the COW after leaving the isolation room.

2. A review of the policy titled Prevention and Management of Multi-Drug Resistant Organisms-Infection, EFF. date: 4/27/16 stated in part: "If possible, dedicate equipment and supplies to one patient. Use disposable equipment for patient in isolation. All patient care equipment must be decontaminated after each use."

3. A review of the policy titled Decontamination of Patient Equipment, Rev date: 4/30/17, stated in part: "Med carts used by Cardiopulmonary and Nursing will be wiped off between patients."

4. An interview was conducted with the Nurse Manager on 8/5/19 at 2:20 p.m. She concurred the nursing staff failed to clean the COW after leaving an isolation room.

C. Based on a tour of the unit, observations and staff interviews it was revealed the nursing staff failed to ensure all medications were properly secured when in the COW. This failure was identified in two (2) COWs observed. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the fourth (4th) floor med surg unit was conducted on 8/5/19 at 1:50 p.m. An observation of two (2) COWs located on the fourth floor medical surgical (med surg) unit revealed all medication drawers were unlocked and had oral medications, IV medication, syringes and needles present in the drawers. One (1) pill was noted on the top of a COW. No nursing staff were present at the COWs at the time of the observation.

2. A review of the policy titled Medication Distribution, Reviewed: 12/29/15 revealed in part: "All healthcare providers must possess medications securely and maintain a secure environment for all medication within and outside the ADC or other dispensing device."

3. An interview was conducted with the Director of Program Improvement on 8/7/19 at 8:00 a.m. She stated after the hack of the computer system two (2) years ago no staff badges would work for the COWs so all drawers were put in an unlock position.

4. An interview was conducted with the Chief Nursing Officer and Nurse Manager during the tour. They concurred the medications were not properly stored in the COWs.

Based on a tour of the unit, observations and staff interviews it was revealed the facility failed to ensure all medications were properly secured when in the computer on wheels (COW). This failure was identified in two (2) COWs observed. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the fourth (4th) floor med surg unit was conducted on 8/5/19 at 1:50 p.m. An observation of two (2) COWs located on the fourth floor medical surgical (med surg) unit revealed all medication drawers were unlocked and had oral medications, IV medication, syringes and needles present in the drawers. One (1) pill was noted on the top of a COW. No staff were present at the COWs at the time of the observation.

2. A review of the policy titled "Medication Distribution, Reviewed: 12/29/15 revealed in part: All healthcare providers must possess medications securely and maintain a secure environment for all medication within and outside the ADC or other dispensing device."

3. An interview was conducted with the Director of Program Improvement on 8/7/19 at 8:00 a.m. She stated after the hack of the computer system two (2) years ago, no staff badges would work for the COWs so all drawers were put in an unlock position.

4. An interview was conducted with the Chief Nursing Officer and Nurse Manager during the tour. They concurred the medications were not properly stored in the COWs.

Based on a tour of the unit, observations and staff interviews, it revealed the facility failed to ensure the staff followed the infection control policy for prevention of communicable diseases. This failure has the potential to adversely affect all patients.

Findings include:

1. A tour of the fourth (4th) floor medical surgical unit was conducted on 8/5/19 at 1:50 p.m. During the tour the nursing staff donned contact precautions personal protective equipment (PPE) and entered an isolation room on the unit. The nursing staff took the computer on wheels (COW) in the isolation room to give medications. After completion of the medication pass the staff removed her PPE and proceeded to the next patient room. The nursing staff failed to properly clean the COW after leaving the isolation room.

2. A review of the policy titled Prevention and Management of Multi-Drug Resistant Organisms-Infection, EFF. date: 4/27/16 stated in part: "If possible, dedicate equipment and supplies to one patient. Use disposable equipment for patient in isolation. All patient care equipment must be decontaminated after each use."

3. A review of the policy titled Decontamination of patient Equipment, Rev date: 4/30/17 stated in part: "Med carts used by Cardiopulmonary and Nursing will be wiped off between patients."

4. An interview was conducted with the Nurse Manager on 8/5/19 at 2:20 p.m. She concurred the staff failed to clean the COW after leaving an isolation room.