HospitalInspections.org

Bringing transparency to federal inspections

1 HEALTHCARE DRIVE MANSFIELD HILL

PHILIPPI, WV 26416

No Description Available

Tag No.: C0222

Based on record review and staff interviews it was determined the facility failed to maintain a preventive maintenance program to ensure the safe operation of all mechanical, electrical and patient care equipment. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/05/19 at approximately 1:18 p.m. revealed no specific equipment maintenance inventories for all essential mechanical, electrical and patient care equipment was provided during survey.

2. Record review on 11/05/19 at approximately 1:21 p.m. revealed the equipment maintenance program was not based off of manufacturer recommendations or other generally accepted standards of practice for an alternate maintenance schedule.

3. In an interview on 11/05/19 at approximately 1:23 p.m. the Support Services Manager verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

No Description Available

Tag No.: C0225

Based on observation, record review and staff interviews it was determined the facility failed to maintain housekeeping and maintenance programs to ensure the premises were clean and orderly. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Observation on 11/04/19 at approximately 11:35 a.m. revealed staff personal protective equipment and respirators being stored in the Soiled Utility Room in the Emergency Room (ER) corridor.

2. Observation on 11/04/19 at approximately 11:45 a.m. revealed a stool and an exam table in Exam Room 2 of the ER that was cracked/torn with exposed tears in the upholstery.

3. Observation on 11/04/19 at approximately 11:48 a.m. revealed a stool in Exam Room 3 of the ER that was cracked/torn with exposed upholstery.

4. Observation on 11/05/19 at approximately 8:05 a.m. revealed a wall fan in the kitchen dish receiving area which appeared covered with dust/debris.

5. Observation on 11/05/19 at approximately 8:07 a.m. revealed the floor tile cover base in the kitchen dish receiving area was cracked and broken.

6. Observation on 11/05/19 at approximately 8:11 a.m. revealed dust/debris on the ceiling in the kitchen dish receiving area.

7. Observation on 11/05/19 at approximately 8:15 a.m. revealed the walls throughout the kitchen were scuffed and missing paint (unsealed).

8. Observation on 11/05/19 at approximately 8:18 a.m. revealed the ceiling air vents throughout the kitchen appeared dirty with dust/debris.

9. Observation on 11/05/19 at approximately 8:22 a.m. revealed cracked floor covering and an approximately four (4) inch by twelve (12) inch piece of missing floor covering in the cook area of of the kitchen.

10. Observation on 11/05/19 at approximately 8:36 a.m. revealed the floor in the walk-in cooler in the kitchen appeared rusty and unsealed.

11. Observation on 11/05/19 at approximately 8:38 a.m. revealed two (2) cabinets in the dining room near the condiment area that had cracked and peeling trim work.

12. Observation on 11/05/19 at approximately 8:50 a.m. revealed three (3) chairs in the lab that had torn or cracked upholstery.

13. Observation on 11/05/19 at approximately 8:52 a.m. revealed unsealed wooden shelving along the floor throughout the lab.

14. Observation on 11/05/19 at approximately 9:06 a.m. revealed painted ceiling tile in the lab specimen draw room which appeared to be stained.

15. Observation on 11/05/19 at approximately 9:42 a.m. revealed an electric scooter (Jazzy Chair) being stored in the CT Room of Radiology.

16. Observation on 11/05/19 at approximately 9:45 a.m. revealed torn and missing flooring in the Computed Tomography (CT) and Mammography areas of Radiology.

17. Observation on 11/05/19 at approximately 9:54 a.m. revealed cracked/broken edge trim on the sink counter in Ultrasound.

18. Observation on 11/05/19 at approximately 10:24 a.m. revealed stained ceiling tile in the Pharmacy.

19. Observation on 11/05/19 at approximately 10:39 a.m. revealed the temperature recorder on the medication refrigerator in the Pharmacy appeared to be recording inaccurate temperatures. The recorded temperatures were noted at thirty-two (32) degrees Fahrenheit and the allowable temperature range was noted as thirty-six (36) to forty (40) degrees Fahrenheit.

20. Record review on 11/05/19 at approximately 11:12 a.m. revealed no documentation of a water management program to reduce Legionella was provided during survey.

21. In an interview on 11/05/19 at approximately 11:14 a.m. the Support Services Manager verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

No Description Available

Tag No.: C0226

Based on record review and staff interviews it was determined the facility failed to ensure proper ventilation in patient care areas. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. Record review on 11/05/19 at approximately 2:12 p.m. revealed no documentation of monitoring of the temperature, humidity or appropriate air pressure relationship for the Pharmacy was provided during survey.

2. Record review on 11/05/19 at approximately 2:15 p.m. revealed no documentation of monitoring of the humidity or appropriate air pressure relationship for the Laboratory was provided during survey.

3. Record review on 11/05/19 at approximately 2:18 p.m. revealed no documentation of monitoring of the temperature, humidity or appropriate air pressure relationship for the facility's clean/sterile storage areas was provided during survey.

4. Record review on 11/05/19 at approximately 2:21 p.m. revealed no documentation of monitoring of the temperature or humidity for the Negative Pressure Isolation Room 500 was provided during survey.

5. Interview on 11/05/19 at approximately 2:25 p.m. with the Support Services Manager verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

No Description Available

Tag No.: C0231

Based on record review and staff interviews it was revealed the facility failed to provide safety from fire and meet the provisions applicable to existing healthcare occupancies of the 2012 edition of the Life Safety Code of the National Fire Protection Association (NFPA) 101. This deficient practice could affect all residents, staff and visitors in the areas referenced. The facility's census was four (4).

Findings include:

1. In reference to Federal Life Safety Code citation K291 the facility failed to ensure the appropriate testing of emergency lighting.

2. In reference to Federal Life Safety Code citation K324 the facility failed to ensure the appropriate testing of the kitchen cooking equipment.

3. In reference to Federal Life Safety Code citation K521 the facility failed to ensure the appropriate installation and testing of fire dampers.

4. In reference to Federal Life Safety Code citation K918 the facility failed to ensure essential electric system maintenance and testing of the emergency generator and related equipment.

5. In an interview on 11/05/19 at approximately 1:05 p.m. the Support Services Manager verified these findings. The findings were also acknowledged by the administrator at the exit interview on 11/06/19 at approximately 12:00 p.m.

PATIENT CARE POLICIES

Tag No.: C0278

Based on observation, document review and staff interviews it was determined the administrator failed to ensure the morgue was in an enclosed area to prevent cross-contamination with clean patient supplies. This failure has the potential to place all patients, staff and all patient supplies at risk for infection and contamination.

Findings include:

1. An observation was conducted on 11/04/19 at approximately 11:06 a.m. The door to Central Supply was propped open and the room also contained two (2) refrigeration body units used for the hospital morgue. Two (2) supply carts containing patient supplies were pushed up against the two (2) refrigeration body units.

2. A review of "Occupational Safety and Health Administration (OSHA) Fact Sheet" and "Health and Safety Recommendations for Workers Who Handle Human Remains," dated 09/05, states in part: "Employers and workers face a variety of health hazards when handling, or working near, human remains. ... The following precautionary measures can help employers and employees remain safe and healthy while handling human remains. ... Personal Protective Equipment. ... Ensure disinfection of vehicles and equipment."

3. A review of OSHA, "Bloodborne pathogens," Standard Number 1910.1030, states in part: "Regulated Waste means liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling ... Source Individual means any individual, living or dead, whose blood or other potentially infectious materials may be a source of occupational exposure to the employee. ...

4. An interview with the Chief Executive Officer (CEO) and the Director of Quality and Risk Management (DQ/RM) was conducted on 11/06/19 at approximately 10:22 a.m. When asked if the morgue refrigeration units should be separated from Central Supply to prevent risk of infection to patient supplies and staff, they concurred the morgue is an infection risk.