HospitalInspections.org

2022-3-057
Based on medical record review, staff interview and document review it was revealed the facility failed to follow the Medical Power of Attorney (MPOA) of patient #1. This failure has the potential to negatively impact all patients who have an MPOA on file.

Findings include:

A record review was conducted for Patient #1. The patient was admitted to the facility on 03/14/22 with a diagnosis of COVID pneumonia. The patient was placed on mechanical ventilation and admitted to the Cardiopulmonary Intensive Care Unit (CPICU). On 03/16/22 at 1:00 p.m., a Case Management narrative note indicated the attending physician was made aware the legal department stated "the MPOA is not legal" and "a HCS [Health Care Surrogate] would need to be appointed." The attending physician agreed to determine the HCS. On 03/17/22 at 3:11 p.m., a Case Management narrative note indicated the attending physician was ordering an Ethics consult to address the HCS issue. On 03/21/22 at 1:11 p.m., Case Manager (CM) #2 documented: "A marriage certificate listing Pts [patient's] name and [spouse], was provided by [Patient #1's spouse], dated August 23, 2015. Certificate placed on chart." On 03/22/22 at 6:26 p.m., Physician #1 documented: "I also discussed the case with [facility's] legal counsel and was informed that [Patient #1's] [spouse] brought a proof of marriage." On 03/31/22 at 9:09 a.m., CM #2 documented that Patient #1's spouse stated, "the only certificate of marriage [they have] is what [they] presented to us previously, stating that they didn't register it because they wouldn't have been able to afford [Patient #1's] insurance if they did." It should be noted a marriage certificate in the state of WV is not a marriage license and is not legally acceptable as proof of marriage.

A telephone interview was conducted with Ethics Committee Member Physician #1 on 11/02/22 at 9:20 a.m. Regarding the HCS for patient #1, Physician #1 stated, "[Patient #1's] MPOA was in question due to there was no dates on the form. This became a legal issue and it was directed to the legal department." Physician #1 stated it was no longer an ethics issue. Physician #1 stated, "The attending physician assigned HCS to [Patient #1's] spouse to make medical decisions. [Patient #1's] family member stated that [Patient #1] and their spouse were not legally married. The hospital legal department asked [Patient #1's] spouse to produce a marriage certificate which was produced by [Patient #1's] spouse. [Patient #1's] family member spoke to me and reported that [Patient #1] and spouse were not legally married. [Patient #1's] family member stated that [Patient #1] wanted family member to make medical decisions for [Patient #1] when [Patient #1] became incapacitated, unable to make these decisions for themselves."

An interview was conducted with CM #1 on 11/02/22 at 9:30 a.m. Regarding the investigation involving Patient #1, CM #1 stated, "There was a question of the legality of [Patient #1's] MPOA because [Patient #1] had signed the MPOA. The MPOA was flagged which caused the legal department to get involved. The legal department viewed the MPOA and determined it was not a legal document since it was not dated. At that point since there was no MPOA on file, a HCS was appointed and the forms was completed for [Patient #1] and put on file."

Review of West Virginia Code, Chapter 48, Article 2, Section 101 (Domestic Relations) revealed it states: "Every marriage in this state must be solemnized under a marriage license issued by a clerk of the county commission in accordance with the provisions of this article. If a ceremony of marriage is performed without a license, the attempted marriage is void, and the parties do not attain the legal status of husband and wife."

§16-30-8. Selection of a surrogate.
(a) When a person is or becomes incapacitated, the attending physician or the advanced nurse practitioner with the assistance of other health care providers as necessary, shall select, in writing, a surrogate. The attending physician or advanced nurse practitioner shall reasonably attempt to determine whether the incapacitated person has appointed a representative under a medical power of attorney, in accordance with the provisions of section four of this article, or if the incapacitated person has a court-appointed guardian in accordance with the provisions of article one, chapter forty-four-a of this code. If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate. In selecting a surrogate, the attending physician or advanced nurse practitioner must make a reasonable inquiry as to the existence and availability of a surrogate from the following persons:

(1) The person's spouse;

(2) The person's adult children;

(3) The person's parents;

(4) The person's adult siblings;

(5) The person's adult grandchildren;

(6) The person's close friends;

A second telephone interview was conducted with Physician #1 on 11/03/22 at 8:30 a.m. Physician #1 was made aware of West Virginia Code Chapter 48, Article 2, Section 101 and asked if they had been aware of this would the outcome of the Ethics Consult have been different. Physician #1 stated it was a legal issue and not an Ethic Committee issue. Physician #1 stated, "If the Ethics Committee knew that the marriage certificate was not a legal document, there is a hierarchy which the hospital should have followed if there is no legal spouse, the next one in line would be the elder child if that child could not serve as HCS, then the next child in line and so on would be asked to serve as HCS for [Patient #1]. If there is no appropriate family member, then the hospital would look at friends and extended family members for HCS. In this case, [Patient #1's] son should have been considered to be the HCS for [Patient #1].

2022-3-058
Based on observation, document review, and staff interview, it was revealed the facility failed to ensure care in a safe setting throughout the Emergency Department (ED) by not ensuring supply carts containing needles in patient care areas were kept locked and secure. This failure has the potential to negatively impact all patients receiving care in the ED.

Findings include:

An observation was conducted of the ED on 11/01/22 at 11:38 a.m. The Director of the ED was present for the tour. The supply cart adjacent to the screening room area in the hallway was unlocked, as the drawers were able to be opened. The drawers contained needles, syringes, and supplies needed for laboratory testing, IV (intravenous) cannula starting, and medication administration. Additional carts were found to be unlocked at the end of the hallway past the trauma bays, in Trauma Bay 1, and in ED Room 19.

An observation was conducted of the ED on 11/02/22 at 3:52 p.m. The supply cart in ED Room 4 was unlocked, as the drawers were able to be opened. The drawers contained needles, syringes, and supplies needed for laboratory testing, IV cannula starting, and medication administration. The supply carts containing similar items were found to be unlocked in ED Rooms 6, 9, 11, and 19. Room 22, which was used as a storage area, also had an unlocked supply cart.

A review was conducted of policy titled "Procurement and Storage of Medication," last published 04/21/22. The policy states in part: "Procedure ... 7. Security ... l. Needles and syringes must be secured at all times in patient care areas, unless the area has no public access."

During observation of the ED on 11/01/22 at 11:38 a.m., the Director of the ED explained the carts should be locked.

An interview was conducted on 11/02/22 at 8:20 a.m. with the ED Charge Nurse (EDCN). Regarding the supply carts located throughout the ED that contained supplies including needles and syringes, the EDCN stated, "All of the supply carts should be locked when not in use and have easy to access keypad locks with identical and easy to remember codes."

A telephone interview was conducted on 11/02/22 at 11:00 a.m. with Registered Nurse (RN) #1. Regarding the supply carts located throughout the ED that contained supplies including needles and syringes, RN #1 stated, "The supply carts are to be locked and do remain locked for the most part. The carts have an easy keypad code to open, and one (1) button is pushed to lock it back."

During observation of the ED on 11/02/22 at 3:52 p.m., the ED Nurse Manager agreed the carts should be locked at all times.

2022-3-058
Based on observation, document review, and staff interview, it was revealed the facility failed to maintain locks on equipment (see Tag A 724) throughout the facility's General Division Emergency Department. This failure has the potential to affect the safety of patients and visitors in the Emergency Department.

2022-3-058
Based on observation and staff interview, it was revealed the facility failed to develop an environment to maintain the safety and well-being of patients in the Emergency Department (ED) by not providing call lights, or a means to call for help and comfort in five (5) patient care areas in the ED, Screening Rooms (SR) 1 through 5. This failure has the potential to negatively impact all patients receiving care in the ED.

Findings include:

An observation was conducted of the ED on 11/01/22 at 11:38 a.m. The Director of the ED was present for the tour. In the area labeled SR 1 through 5, there are recliners, with draw curtains able to be pulled around them. There were no patients there at the time of observation. There were no call lights provided in this area. The Director of the ED explained a nurse would be assigned to patients there, and would check on them frequently, and be nearby if they needed anything. The area is mostly used for physicians to quickly screen patients and send them back to the waiting area, but it can also be used for treatment such as intravenous (IV) infusions or fluids for patients able to sit upright.

An observation was conducted of the ED on 11/02/22 at 3:52 p.m. An observation was made in the ED of the SR's. The area contained five (5) recliner chairs. Three (3) patients were present in the chairs, patient #11 in SR 1, patient #12 in SR 3, and patient #13 in SR 4. Patient #11 had a one-to-one (1:1) observation sitter directly across from the patient. Patients #12 and 13 did not have staff with them.

An interview was conducted on 11/02/22 at 8:20 a.m. with the ED Charge Nurse (EDCN). Regarding the area of five (5) SR recliner chairs, the EDCN stated that at times of high census, "Patients are placed there, screened by the providers, and then returned to the waiting room. Other patients may remain in the chairs to receive antibiotics or IV fluids. The patients may remain in the recliner chairs throughout their ED stay or transfer to an ED bed when one becomes available." The EDCN concurred that, "There are no call lights located at any of the five (5) Screening Room recliners."

A telephone interview was conducted on 11/02/22 at 11:00 a.m. with Registered Nurse (RN) #1. Regarding the SR area with five (5) recliner chairs, RN #1 stated, "The triage nurse is responsible for the patients in the recliner chairs, and the waiting room nurse takes their vitals every hour. There are no call lights for the chairs, so I guess the patient can tell the waiting room nurse what is needed when rounding."

During the observation of the ED on 11/02/22 at 3:52 p.m., the ED Nurse Manager explained the patients in the SR area would have to call out for help to nurses nearby, as there were no call lights provided to patients in the SR area.

2022-3-058
Based on observation, staff interview, and document review, it was revealed the facility failed to maintain equipment to ensure an acceptable level of safety for patients throughout the facility's General Division Emergency Department (ED) by not ensuring supply carts had functioning locking mechanisms. This failure has the potential to negatively impact all patients receiving care in the ED.

Findings include:

An observation was conducted of the ED on 11/01/22 at 11:38 a.m. The Director of the ED was present for the tour. The supply cart adjacent to the screening room area in the hallway was unlocked, as the drawers were able to be opened. The drawers contained needles, syringes, and supplies needed for laboratory testing, intravenous (IV) cannula starting, and medication administration. Additional carts were found to be unlocked at the end of the hallway past the trauma bays, in Trauma Bay 1, and in ED Room 19.

An observation was conducted of the ED on 11/02/22 at 3:52 p.m. The supply cart in ED Room 4 was unlocked, as the drawers were able to be opened. The drawers contained needles, syringes, and supplies needed for laboratory testing, IV cannula starting, and medication administration. The supply carts containing similar items were found to be unlocked in ED Rooms 6, 9, 11, and 19. Room 22, which was used as a storage area, also had an unlocked supply cart.

During the observation on 11/01/22 at 11:38 a.m., the Director of the ED explained about the unlocked carts, "We need to check them all, the batteries must be going dead in some of them."

During the observation of the ED on 11/02/22 at 3:52 p.m., the ED Nurse Manager explained there had been a couple supply carts which were unable to be locked, and a maintenance request was put in to fix them.

A review was conducted of "Request Work Order" submitted on 11/02/22 at 10:30 a.m. The request states, "We have 11 [eleven] carts that are not locking. I'm pretty sure it's maybe the battery." Maintenance responded to the request on 11/02/22 at 2:20 p.m.