HospitalInspections.org

Bringing transparency to federal inspections

314 SOUTH WELLS STREET

SISTERSVILLE, WV 26175

COMPLIANCE WITH FED, ST, AND LOCAL LAWS

Tag No.: C0810

Based on document review and interview it was revealed the facility failed to follow applicable State regulations by declaring a "red alert" diversion status for a period of ten (10) days and diverting emergency patients arriving by ambulance to other facilities. (See tag C 814) This failure has the potential to cause great harm to all patients presenting to the hospital for care.

COMPLIANCE STATE AND LOCAL LAWS AND REGS

Tag No.: C0814

Based on document review and interview it was revealed the facility failed to follow applicable State regulations by declaring a "red alert" diversion status for a period of ten (10) days and diverting emergency patients arriving by ambulance to other facilities. This failure has the potential to cause great harm to all patients presenting to the hospital for care.

Findings include:

1. "West Virginia Office of Emergency Medical Services Statewide Protocols Ambulance Diversion Policy," Version 1.1 dated 01/01/2016 was reviewed. It states in part: " ...B. Diversion Criteria: The determination to place a hospital on red alert status and consider diversion of ambulances from any hospital emergency department can only be made when two (2) of the following criteria are met. Criteria #1 must always be one (1) of the two (2) criteria prompting the red alert. 1. The emergency department is overloaded, i.e., filled to capacity with patients whose conditions do not allow for extended delay in treatment; or there is already an overwhelming number of critical patients, and any additional critical patients would exceed the care capability of the facility. D.3 ...At no time may a facility be on red alert status for more than six (6) hours in a twenty-four (24) hour period beginning at twelve (12) midnight."

2. On 08/23/21 at 11:00 a.m. during entrance conference the Chief Executive Officer (CEO) explained the Health System had been a victim of a Ransomware attack on 08/15/21 and they were currently unable to provide access to the Electronic Medical Record System. The facility has been documenting on paper since the day of the attack. The facility had also declared a "red diversion" for the Emergency Department (ED) to defer the ambulances from bringing patients due to the Ransomware attack.

3. An interview was conducted with the Chief Medical Officer (CMO) on 08/24/21 at 11:05 a.m. The CMO stated in part, " ...to maintain quality of care for our patients, we will document everything on paper. We would treat every patient presenting to the ED as if they were a new patient to our system with no medical information on file." Regarding emergent diagnostic testing, the CMO stated, "We declared a red diversion status category and communicated this to EMS (Emergency Medical Services) as well as the whole state. Ambulances are diverted to other facilities as well as they can be. Simple X-ray plain films can be done and read by our ED Physicians, and to be confirmed by a radiologist at a later date. If we feel we cannot provide the services required to the patient, we will transfer the patient to where the services can be provided."

4. An interview was conducted with the CEO on 08/24/21 at 2:15 p.m. After re-reading the "Ambulance Diversion Policy" the CEO stated, "The Hospital should have been on a yellow diversion since the Ransomware attack on 08/15/21 instead of a red diversion. It has now been changed."

EMERGENCY SERVICES

Tag No.: C0880

Based on interview and document review it was revealed the facility failed to meet the needs of its inpatients and outpatients by not providing diagnostic radiology Computed Tomography (CT) scans, Ultrasound or X-rays to all patients presenting to the hospital Emergency Department since 08/15/21. (See tag C 884) This failure has the potential to cause great harm to all patients presenting to the hospital for care.

EQUIPMENT, SUPPLIES, AND MEDICATION

Tag No.: C0884

Based on interview and document review it was revealed the facility failed to meet the needs of its inpatients and outpatients by not providing diagnostic radiology Computed Tomography (CT) scans, Ultrasound or X-rays to all patients presenting to the hospital Emergency Department since 08/15/21. This failure has the potential to cause great harm to all patients presenting to the hospital for care.

Findings include:

1. During a flash tour of the facility on 08/23/21 at 11:40 a.m. the Director of Quality explained, "We have not done any CT scans or Ultrasounds since the Ransomware attack due to the being unable to transmit the images to the Radiologist. We can only do simple X-rays to be read by the ED (Emergency Department) physician."

2. An interview was conducted with the Radiology Technologist Supervisor (RTS) on 08/24/21 at 10:20 a.m. The RTS stated, "Since the Ransomware attack we have not done any X-rays unless ordered by the ED physician. We have not done any Ultrasounds or CT scans since we can't transmit the images to our Radiologist. We rescheduled all the outpatient radiology testing or referred them to a different location if they couldn't wait"

3. An interview was conducted with the Chief Medical Officer (CMO) on 08/24/21 at 11:05 a.m. Regarding emergent diagnostic testing the CMO stated, "We declared a red diversion status category and communicated this to EMS (Emergency Medical Services) as well as the whole state. Ambulances are diverted to other facilities as well as they can be. Simple X-ray plain films can be done and read by our ED Physicians, and to be confirmed by a radiologist at a later date. If we feel we cannot provide the services required to the patient, we will transfer the patient to where the services can be provided."

4. An interview was conducted with the Chief Executive Officer (CEO) on 08/24/21 at 2:15 p.m. Regarding the CT scans the CEO stated, "We feel it would be faster to transfer the patient to a different facility for the scans rather than waiting more than two (2) hours for the image disk to be driven to the Radiologists in Wheeling. We are in the process as well, of switching Radiology groups from Wheeling to our Health system."

5. A policy titled "Critical Access Hospital Health Care Services Policy," last revised 04/30/15 was reviewed. The policy states in part: "Policy/Procedure: The following CAH (Critical Access Hospital) Health Care Services available at SGH (Sistersville General Hospital) and what services are furnished through referral ...Radiology: Included but not limited to: X-ray, CT, MRI, Echo's, Mammography and Ultrasounds."

MAINTENANCE

Tag No.: C0914

Based on document review and staff interview it was revealed the facility failed to provide emergency lighting in accordance with National Fire Protection Association (NFPA) 101. The facility's census was two (2).

Findings include:

1. Document review on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed the facility failed to conduct annual tests of the emergency lighting in accordance with NFPA 101.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.


Based on observation and staff interview it was revealed the facility failed to ensure the facility was protected throughout by an approved automatic sprinkler system in accordance with NFPA 13. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was two (2).

Findings include:

1. Observation during the facility inspection tour on 08/24/21 between the hours of 8:30 a.m. and 3:30 p.m. revealed a sprinkler head in emergency room (ER) three (3) closet. A light fixture is located less than twelve (12) inches away from a sprinkler head and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

2. Observation during the facility inspection tour on 08/24/21 between the hours of 8:30 a.m. and 3:30 p.m. revealed a sprinkler head in the medical records room two (2) closet. A light fixture is located less than twelve (12) inches away from a sprinkler head and exceeded the maximum allowable distance of the sprinkler deflector above the bottom of the light fixture.

3. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.


Based on document review and staff interview it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with NFPA. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was two (2).

Findings include:

1. Facility document review conducted on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed a first quarter, midnight shift fire drill conducted on 03/10/21 at 6:30 a.m. and the second quarter, midnight shift fire drill conducted on 06/17/21 at 6:00 a.m. The fire drills are held within one (1) hour of each other and considered patterned and not at unexpected times under varying conditions.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.


Based on facility document review and staff interview it was revealed the facility failed to maintain the electrical system maintenance and testing requirements in accordance with NFPA 99. The facility's census was two (2).

Findings include:

1. Facility document review conducted on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed the facility failed to test receptacles located at patient bed locations in accordance with NFPA 99.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.

BUILDING SAFETY

Tag No.: C0944

Based on document review and staff interview it was determined the facility failed to conduct fire drills at unexpected times under varying conditions in accordance with National Fire Protection Association (NFPA). This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was two (2).

Findings include:

1. Facility document review conducted on 08/23/21 between the hours of 11:30 a.m. and 4:30 p.m. revealed a first quarter, midnight shift fire drill conducted on 03/10/21 at 6:30 a.m. and the second quarter, midnight shift fire drill conducted on 06/17/21 at 6:00 a.m. The fire drills are held within one (1) hour of each other and considered patterned and not at unexpected times under varying conditions.

2. The aforementioned deficiency was discussed with the Plant Operations Director at the time of discovery and again with the Administrator on 08/24/21 at approximately 4:00 p.m. at the time of exit and they agreed this deficiency needed corrected.

PROVISION OF SERVICES

Tag No.: C1004

Based on document review and interview it was revealed the facility failed to provide diagnostic radiology services including Computed Tomography (CT) scans, Ultrasound or X-rays to all inpatients and patients presenting to the hospital since 08/15/21. (See tag C 1030). This failure has the potential to cause great harm to all patients presenting to the hospital for care.

RADIOLOGY SERVICES

Tag No.: C1030

Based on document review and interview, it was revealed the facility failed to furnish diagnostic radiology services including Commuted Tomography (CT) scans, Ultrasound, or X-rays to all inpatients and patients presenting to the hospital since 08/15/21. This failure has the potential to cause great harm to all patients presenting to the hospital for care.

Findings include:

1. A policy titled "Critical Access Hospital Health Care Services Policy," last revised 04/30/15 was reviewed. The policy states in part: "Policy/Procedure: The following CAH (Critical Access Hospital) Health Care Services available at SGH (Sistersville General Hospital) and what services are furnished through referral ...Radiology: Included but not limited to: X-ray, CT, MRI, Echo's, Mammography and Ultrasounds."

2. During a flash tour of the facility on 08/23/21 at 11:40 a.m. the Director of Quality explained, "We have not done any CT scans or Ultrasounds since the Ransomware attack due to the being unable to transmit the images to the Radiologist. We can only do simple X-rays to be read by the ED (Emergency Department) physician."

3. An interview was conducted with the Radiology Technologist Supervisor (RTS) on 08/24/21 at 10:20 a.m. The RTS stated, "Since the Ransomware attack we have not done any X-rays unless ordered by the ED physician. We have not done any Ultrasounds or CT scans since we can't transmit the images to our Radiologist. We rescheduled all the outpatient radiology testing or referred them to a different location if they couldn't wait"

4. An interview was conducted with the Chief Medical Officer (CMO) on 08/24/21 at 11:05 a.m. Regarding emergent diagnostic testing the CMO stated, "We declared a red diversion status category and communicated this to EMS (Emergency Medical Services) as well as the whole state. Ambulances are diverted to other facilities as well as they can be. Simple X-ray plain films can be done and read by our ED Physicians, and to be confirmed by a radiologist at a later date. If we feel we cannot provide the services required to the patient, we will transfer the patient to where the services can be provided."

5. An interview was conducted with the Chief Executive Officer (CEO) on 08/24/21 at 2:15 p.m. Regarding the CT scans the CEO stated, "We feel it would be faster to transfer the patient to a different facility for the scans rather than waiting more than two (2) hours for the image disk to be driven to the Radiologists in Wheeling. We are in the process as well, of switching Radiology groups from Wheeling to our Health system."

NURSING SERVICES

Tag No.: C1050

Based on document review, medical record review and interview it was revealed the facility failed to implement a nursing care plan for two (2) of two (2) patients (patients #12 and 13) who were hospitalized during a computer downtime. The failure to implement a nursing care plan has the potential to adversely affect the care of every patient as the communication between nursing and other healthcare staff to achieve health care outcomes is lost.

Findings include:

1. A review of the facility policy entitled 'Nursing Plan of Care,' revised date 10/05 revealed in part: "The nursing care plan will be initiated with twelve (12) hours of the patient's admission and will be used for the implementation of the nursing process ..."

2. A review of the facility policy entitled 'Downtime Standard Work-Nursing,' no date listed, has no instructions for implementing nursing care plans during a computer downtime.

3. A review of patient #12's medical record on 8/24/21 revealed the patient did not have a paper nursing care plan implemented during the computer downtime.

4. A review of patient # 13's medical record 0 8/24/21 revealed the patient had been admitted on 8/19/21 and a nursing care plan had not been implemented.

5. An interview with the Registered Nurse on 8/24/21 at approximately 2:40 p.m. revealed they did not have downtime care plan forms.

6. An interview was conducted with the Director of Nursing on 8/24/21 at 3:15 p.m. and he concurred with these findings.

CLINICAL RECORDS

Tag No.: C1100

Based on document review and interview it was revealed the facility failed to have the ability to access any patient medical records due to a Ransomware attack on the Health System's server on 08/15/21 which had yet to be resolved. (See tag C 1104). This failure has the potential to cause great harm to any patients presenting to the facility for care.

RECORDS SYSTEM

Tag No.: C1104

Based on document review and interview it was revealed the facility failed to have the ability to access any patient medical records due to a Ransomware attack on the Health System's server on 08/15/21 which had yet to be resolved. This failure has the potential to cause great harm to any patients presenting to the facility for care.

Findings include:

1. A policy titled "Functions of the Medical Record Department," last review date 09/06/18 was reviewed. The policy states in part: "Policy: It is the policy of Sistersville General Hospital to maintain facilities and services as are adequate to provide medical records that are accurately documented, readily accessible, and that can be used for retrieving and compiling information ..."

2. A policy titled "Records Management," effective 04/01/06 was reviewed. The policy states in part: "To establish the policy and procedure for the creation, use, maintenance, retention, preservation, and disposal of Sistersville General Hospital records. Policy: 1 ...Records are retained in accordance with all applicable laws and regulations and this policy ...4. Records containing confidential information will be securely maintained, controlled, and protected to prevent unauthorized access."

3. On 08/23/21 at 11:00 a.m. during entrance conference, the Chief Executive Officer (CEO) explained the Health System had been a victim of a Ransomware attack on 08/15/21 and they were currently unable to provide access to the Electronic Medical Record System.

4. An interview was conducted with the Chief Medical Officer (CMO) on 08/24/21 at 11:05 a.m. The CMO stated in part, " ...to maintain quality of care for our patients, we will document everything on paper. We would treat every patient presenting to the ED as if they were a new patient to our system with no medical information on file."

DISCHARGE PLANNING PROCESS

Tag No.: C1404

Based on document review, medical record review and interview it was revealed the facility failed to ensure discharge planning was implemented for two (2) of nine (9) patients (patients #12 and 13). This failure has the potential to adversely affect all patients who may require assistance at the time of discharge.

Findings include:

1. A review of the facility policy entitled 'Discharge Planning,' last revised date 2/09 revealed in part: "The Registered Nurse will be responsible for assessing the patient's ability to manage their everyday physical, mental and psychosocial needs and will complete the Discharge Plan section on the POC ... Social services will review all admissions and the discharge planning note entry for any needs that have been identified ..."

2. A review of patient #12's medical record revealed the patient had been admitted on 7/30/21 and there was no discharge planning documentation in the paper chart. The electronic medical record was not available.

3. A review of patient #13's medical record revealed the patient had been admitted on 8/19/21 and there was no discharge planning documentation.

4. An interview conducted with the Registered Nurse on 8/24/21 at approximately 2:40 p.m. revealed patient #12 did not have an order for social services for discharge planning

5. An interview was conducted with the Director of Nursing on 8/24/21 at approximately 3:15 p.m. and he concurred with these findings.