The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

LOGAN REGIONAL MEDICAL CENTER 20 HOSPITAL DRIVE LOGAN, WV 25601 May 9, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on review of policies, documented complaints and staff interviews, it was determined the hospital failed to ensure all departments followed the established policy for investigating and documenting patient complaints for four (4) of four (4) complaints reviewed (C1, C2, C3 and C4) in the month of April 2012. This has the potential for patient complaints not being investigated as required.

Findings include:

1. The hospital policy "Patient Complaint/Grievance Policy", last reviewed 10/09, states (regarding grievances) "The Senior Director, Risk Manager, Department Manager or Hospital Designee receiving the grievance shall record the appropriate patient information, complaint and its resolution (if concluded) on the Complaint Form and/or electronic incident reporting system and forward the original of same to Administration/Hospital Designee for entry into the log within one (1) business day after receipt of the grievance."

2. The Risk Manager was interviewed on 5/9/2012 at about 9:30 a.m. and she stated she is the hospital designee responsible for maintaining the complaint/grievance log.

3. The hospital's documented log of complaints for the month of April 2012 was requested and reviewed. There were no complaints listed on the log for the Emergency Department (ED). The ED Nurse Manager was interviewed on 5/8/2012 at about 2:40 p.m. She stated there had been complaints made regarding care in the ED in the month of April. A second request was made for the complaints specific to the ED. A total of four (4) copies of e-mails from the administrative secretaries to the ED Nurse Manager were provided for review. The e-mails contained information relative to four (4) separate complaints made in the month of April 2012 regarding care provided in the ED (complaints #C1, C2, C3, and C4). There was no documented investigation such as record reviews or interviews with staff with the complaints. The complaints were not logged on the Risk Manager's log of complaints.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
A. Based on review of medical records, hospital policies and staff interviews, it was determined the hospital failed to ensure that staff followed the established policy which requires a physician's order for insertion of urinary catheters for four (4) of six (6) patient who received a catheter (#1, 2, 6, 8). This has the potential for negative patient outcomes.

Findings include:

1. The hospital policy "Catheter, Insertion of Urinary Internal Care of Indwelling Foley Urinary External (Texas)", last reviewed 9/08, states "An LPN or RN may insert catheters at the order of the physician."

2. An emergency department (ED) nurse #1 was interviewed on 5/9/2012 at 10:00 am and she stated "physician's order is required to insert a Foley or straight catheter."

3. Review of the medical record for patient #1 revealed she was treated in the ED on 4/12/2012. During the visit a urine sample was obtained with a straight catheter. There was no physician order for the procedure.

4. Review of the medical record for patient #2 revealed she was treated in the ED on 4/12/2012. During the visit a Foley catheter was inserted. There was no physician order for the procedure.

5. Review of the medical record for patient #6 revealed he was treated in the ED on 4/5/2012. During the visit a Foley catheter was inserted. There was no physician order for the procedure.

6. Review of the medical record for patient #8 revealed she was treated in the ED on 4/11/12. During the visit a Foley catheter was inserted. There was no physician order for the procedure.

B. Based on review of policies, medical records and staff interview, it was determined the hospital failed to develop a policy relative to documentation of the discontinuation of an intravenous (IV) catheter upon discharge from the Emergency Department (ED) for two (2) of two (2) records reviewed of patients who were discharged from the ED (patients #1 and 3B). This has the potential for patients to be discharged from the ED with an IV catheter left in place.

Findings include:

1. Review of hospital policy "IV Therapy - Venipuncture and Care of", last reviewed 10/04, revealed the policy failed to address discontinuation of IV catheters upon discharge.

2. An ED staff nurse was interviewed on 5/9/2012 at 10:00 a.m. She stated that the nursing staff do not document when an IV catheter is removed prior to discharging a patient from the ED.

3. Review of the medical record for patient #1 revealed an IV was inserted in the ED during the visit on 4/12/2012. The patient left the ED against medical advice to return to her home. There was no documented evidence in the medical record that the IV was removed prior to the patient leaving the hospital.

4. Review of the medical record for patient #3B revealed the patient had an IV in the ED to receive medication during a visit on 4/1/2012. The patient was discharged to her home from the ED. There was no documented evidence in the medical record that the IV was removed prior to the patient leaving the hospital.