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.

WELCH COMMUNITY HOSPITAL 454 MCDOWELL STREET WELCH, WV 24801 Oct. 16, 2014
VIOLATION: QAPI PERFORMANCE IMPROVEMENT PROJECTS Tag No: A0297
Based on document review and staff interview it was determined the hospital must document what quality improvement projects are being conducted and the reasons for these projects based on the scope and complexity of the hospitals services. When hospitals fail to clearly identify what quality projects need to be conducted based on analysis of hospital needs, priorities and identified concerns can result in failure to identify needed opportunities for improvement which can result in negative or adverse patient outcomes.

Findings include:

Review of the Quality Assurance and Performance Improvement (QAPI) Plan for 2014 states in part the following:

"The West Virginia Department of Health and Human Resources (WVDHHR), the Medical Executive Committee (MEC) and hospital Administration will support and dedicate appropriate resources to establish, implement and continually provide for the performance measurement, assessment and improvement of activities related to patient care and customer satisfaction."

Review of the MEC committee minutes for 2013 to present revealed there is a performance improvement team (PIT) working on medication safety and critical timing of medications. There is also a team working on Clostridium Difficle. Also discussed in meetings was a Surgical Care Improvement Project (SCIP).

There was no documentation in the MEC committee minutes of a discussion and approval for the quality indicators the QA program has selected and the reasons these indicators were selected such as information from the hospitals quality improvement organization or identified hospital priorities.

The Chief Operations Officer (COO) and the Quality Manager were both interviewed on 10/16/14 at 11:10 AM. The COO said the Medical Executive Committee (MEC) has the authority for the Quality Assurance Program and these meetings occur on a monthly basis. When questioned as to who determines the quality indicators or projects she said hospital staff, departments or the MEC committee can identify and initiate a project. She stated there is a hospital wide project for Clostridium Difficle for 2014.
The COO and Director of Quality were asked to review the MEC committee minutes from 2013 to present. The COO agreed the meetings did not have documentation of the discussion and approval of quality indicators the QA program is using and the reasons these indicators were selected.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and staff interview, it was determined the facility failed to provide adequate monitoring of patients waiting for both their initial rapid emergency assessment and their full medical screening examination after presentation to the Emergency Department (ED). This has the potential to negatively impact all patients presenting for treatment due to the staff's inability to rapidly recognize and intervene in the event a waiting patient's status suddenly deteriorates.

Findings include:

1. A tour of the facility ED was conducted, attended by the ED Nurse Manager (NM) on 10/14/14 at 10:40 a.m. The waiting room was located to the right of the main entrance and approximately ten (10) feet from the door to the ED. There was no call bell or buzzer noted within the waiting room area. The only window located in the waiting room other than those looking out of the building, gave a view of the interior of a small office marked "Security", which was empty at the time of this observation. The door to the ED was noted to be solid and locked. A sign was noted on the door instructing patients to knock or ring the bell for service. The bell was located immediately to the right of the door. A small, covered window with a ledge was noted to the right of the door with a narrow bottom portion of the window open to the interior of the room behind that wall. Within the ED, a monitor was noted mounted to the top of the nurse's desk with a screen divided into four (4) views, one of which, according to the NM was the view of a portion of the waiting room.

2. An interview was conducted with the ED NM on 10/14/14 during the tour described above. She was asked to describe the process by which patients present and are seen in the ED. She stated the patient initially presents to the small window to the right of the ED door and fills out a pink slip with their name and presenting problem, then slides the slip of paper under the bottom of the window to the inside, which she stated was the Triage Room (where patients receive their first rapid assessment of their presenting problem and are assigned a level of urgency based on that assessment). She stated the patient then returns to the waiting room. She stated the Triage Registered Nurse (RN) calls patients to the Triage room based on judgement of the most urgent cases first. Following the triage process the patient is then brought to a bed in the ED for medical screening or sent back to the waiting room. She stated the current Triage policy defines five (5) levels of care ranging from level one (1), the most urgent to level five (5) the least urgent. She stated all patients assessed at levels one (1) and two (2) are immediately place in ED beds. She stated patients assessed at all lower levels of urgency are placed in beds as rapidly as possible but may also be candidates for waiting in the waiting room as ED beds become available. She stated all patients are reassessed for changes in their conditions per policy, with the time parameters of how frequent the reassessment is conducted corresponding to the status they are assigned at Triage. She stated there is no current policy, schedule, assignment, or expectation regarding the monitor at the nurse's desk. She stated "whoever is available watches it, usually the unit clerk or the Triage nurse". She agreed no ED staff member can visualize a patient presenting to register for treatment at the ED. She agreed there were times nobody was at the nurse's desk to observe the monitor and therefore, observe patients in the waiting room. She further agreed view of the waiting room was, at the time of this investigation, limited in its view of the entire area, adding there is currently one camera in operation for that purpose.

3. An interview was conducted with the facility's Chief Executive Officer (CEO) on 10/15/14 at 2:00 p.m. He stated he currently has plans to improve visibility by security camera in all areas of the facility, including the ED. He stated he participated in a recent Root Cause Analysis of a sentinel event (an unexpected event resulting in a serious negative impact on a patient) in which a second camera was recommended for the ED waiting area. He stated the camera had not been installed by the target date of 9/1/14 due to financial constraints. He was unable to recall any discussion of alternative means of increasing ED staff visibility and availability to patients in the waiting room.

4. An interview was conducted with the ED Medical Director on 10/16/14 at 11:50 a.m. He stated he desired an improvement in the Triage process in the facility and is currently planning steps to "streamline" the process for patients. He stated he desired to see improvement in the visualization of patients presenting for treatment and while waiting in the waiting room. He was unable to recall any discussion with administrators or ED staff of changes to staffing patterns for more reliable monitoring of the camera view of the waiting room.

5. An interview was conducted with the ED Assistant Nurse Manager on 10/14/14 at 12:50 p.m. She stated the view of the waiting room on the monitor at the nurse's desk does not show the entire room. She stated if someone in the waiting room needs help, they must (themselves or a family member) knock on the ED door or go to the registration desk to call for help.

6. An interview was conducted with ED RN #1 on 10/14/14 at 12:10 p.m. She stated when she must send a triaged patient to the waiting room, she tells them to "let us know if there are any problems", and stated there is not always a staff member watching the waiting room monitor screen.

7. An interview was conducted with ED RN #2 on 10/15/14 at 1:00 p.m. She stated currently "doesn't like" the location of the waiting room, but is glad to have the camera. She stated there is sometimes no staff member available to watch the monitor screen.

8. An interview was conducted with ED RN #3 on 10/15/14 at 1:20 p.m. She stated all patients sent to the waiting room are instructed to "knock" if there are any changes in their condition while waiting to be seen. She stated lack of visualization of the waiting room by ED staff "could be a bad situation", and agreed the monitor screen is not watched by staff at all times.

9. An interview was conducted with ED RN #4 on 10/14/14 at 12:45 p.m. She stated she instructs all patients waiting for treatment following triage to "knock on the door" for any changes in their condition. She stated the camera viewing the waiting room "does not show the whole room". She agreed there are times no staff member is viewing the monitor screen.

10. An interview was conducted with ED RN #5 on 10/14/14 at 1:15 p.m. She stated "the waiting room is not safe", she instructs patients to knock on the ED door if their condition worsens and she agreed the monitor screen is sometimes not in view of ED staff.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
A. Based on document review and staff interview it was determined that quality assurance failed to monitor, measure, analyze and track quality indications which were developed as a result of hospital specific evidence, peer review research or from information received from their quality improvement organization (QIO). When there is not an effective and comprehensive Quality program based on hospital specific evidence, peer review or information from the QIO can result in missed opportunities to improve patient care and safety with possible negative patient outcomes.

Findings include:

Review of the Quality Assurance and Performance Improvement (QAPI) Plan for 2014 states in part the following:

"The West Virginia Department of Health and Human Resources (WVDHHR), the Medical Executive Committee (MEC) and hospital Administration will support and dedicate appropriate resources to establish, implement and continually provide for the performance measurement, assessment and improvement of activities related to patient care and customer satisfaction."

The Director of QAPI oversees the coordination of the QAPI program. The MEC is delegated the primary authorization over activities related to functions of quality assessment and performance improvement. QAPI activities include how the hospital designs, measures, assess and improves important processes.

All QAPI activities are incorporated into a systematic, organizational wide approach through integrated monitoring of Performance Improvement Teams (Pits).

The MEC reviews any immediate performance improvement or quality issues.

The MEC will recommend all performance improvement teams (PITs) to address performance issues which require a multidisciplinary, multidepartmental approach. The hospital will have at least two functioning PITs per year. Minutes from PITs will be presented to the Director of QAPI for presentation at the MEC.

Review of the MEC committee minutes for 2013 to present revealed documentation of a performance Improvement team that is working on medication safety and critical timing of medications. There is also a team working on Clostridium Difficle.

There was no documentation in the MEC committee minutes of a discussion and approval of the quality indicators the QA program has selected and the reasons these indicators were selected such as information from the hospitals quality improvement organization, hospital specific evidence or peer related research.

Additional review of monthly MEC committee reports from January 2013 to September 2014 revealed routine documentation of actions the committee took was to approve committee minutes/reports, policies, formulary changes, appointment of medical staff members and a reference about substantiated complaints were addressed in an appropriate manner. Specific actions which were recorded were to:

1. Add Lactinex and yogurt to dietary trays.
2. Have utilization review and track surgical care improvement failures by physicians and report findings.
3. For patients who are transferred to the emergency department from another clinic there must be communication between physicians.
4. Requirement that all physicians are to put orders in for all radiological exams and to order a three (3) view on all extremity exams.
5. In July 2014 the committee reviewed a sentinel event and an action plan was discussed (no documentation of what the action plan was, any process changes and who would be monitoring and reporting on the new plan).

The Chief Operations Officer (COO) and the Quality Manager were both interviewed on 10/16/14 at 11:10 a.m. The COO and Director of Quality were asked to review the MEC committee minutes from 2013 to present. The COO agreed the meetings lacked analysis of reports which were presented. Also, she agreed there was no documentation of recommendations for health care process changes with monitoring and reporting requirements to the committee. She also concurred there was no documentation where the MEC committee discussed and approved the quality indicators the QA program will be using and the reasons these indicators were selected.

B. Based on document review and staff interview it was determined the hospital failed to enforce its guidelines for the quality improvement plan which requires that monthly the Department Heads will monitor identified quality concerns with quarterly reporting of those findings to the Director of QAPI for review and presentation in the Hospital Wide QAPI program. When there is not an effective and comprehensive Quality program which involves all hospital departments can result in missed opportunities to improve patient care and safety with possible negative patient outcomes.

Findings include:

Review of the Quality Assurance and Performance Improvement (QAPI) Plan for 2014 states in part the following:

The Medical Executive Committee (MEC) is delegated the primary authorization over activities related to functions of quality assessment and performance improvement. QAPI activities include how the hospital designs, measures, assess and improves important processes.

All QAPI activities are incorporated into a systematic, organizational wide approach through integrated monitoring of Performance Improvement Teams (Pits).

Priorities for hospital wide QAPI activities at the hospital will be designed to improve patient processes and outcomes. These priorities will be developed by the MEC's QAPI function with participation of all hospital disciplines represented through the Department QAPI Committee and approval through the MEC.

Department Heads are to monthly monitor identified quality concerns with quarterly reporting of those findings to the Director of QAPI for review and presentation in the Hospital Wide QAPI program. The MEC reviews any immediate performance improvement or quality issues.

The Director of QAPI meets quarterly with all hospital departments to discuss QAPI findings for each department. The Director of QAPI submits a quarterly report of hospital wide QAPI as well as minutes from the departmental QAPI meetings.

Review of the MEC committee minutes for 2013 to present revealed the only members who attended the meetings were members of the medical staff, the Chief Executive Officer (CEO), Chief Operations Officer (COO), the pharmacist (once a quarter), the Director of Quality and the Director of Nursing (DON).

The committee minutes lacked documentation of any departmental quality reports from obstetrics/nursery, intensive care, emergency services, respiratory therapy, environmental services, laboratory, dietary, radiology or social services.

The Chief Operations Officer (COO) and the Quality Manager were both interviewed on 10/16/14 at 11:10 a.m. The COO said the Medical Executive Committee (MEC) has the authority for the Quality Assurance Program and these meetings occur on a monthly basis. The COO and Director of Quality were asked to review the MEC committee minutes from 2013 to present. They were questioned as to where the quality assurance reports for all hospital departments are documented in the meeting minutes. The COO agreed the only departments providing quality assurance reports are safety, pharmacy and infection control. The COO said a lot of discussion occurs in the different departments but this is not being documented in the MEC committee minutes.




C. Based on document review and staff interview it was determined the hospital failed to enforce its guidelines for the quality improvement plan which requires that the department heads will monitor identified quality concerns monthly and report those findings quarterly to the Director of QAPI for review and presentation in the hospital-wide QAPI program. This failure to have an effective and comprehensive quality program which involves all hospital departments can result in missed opportunities to improve patient care and safety, with possible negative patient outcomes.

Findings include:

1. Review of the hospital's Quality Assurance and Performance Improvement (QAPI) Plan for 2014 states, in part, the following:

"The Medical Executive Committee (MEC) is delegated the primary authorization over activities related to functions of quality assessment and performance improvement. QAPI activities include how the hospital designs, measures, assesses and improves important processes...All QAPI activities are incorporated into a systematic, organizational wide approach through integrated monitoring of Performance Improvement Teams (PITs)...Priorities for hospital wide QAPI activities at the hospital will be designed to improve patient processes and outcomes. These priorities will be developed by the MEC's QAPI function with participation of all hospital disciplines represented through the Department QAPI Committee and approval through the MEC...Department Heads are to monthly monitor identified quality concerns with quarterly reporting of those findings to the Director of QAPI for review and presentation in the Hospital Wide QAPI program. The MEC reviews any immediate performance improvement or quality issues...The Director of QAPI meets quarterly with all hospital departments to discuss QAPI findings for each department. The Director of QAPI submits a quarterly report of hospital wide QAPI as well as minutes from the departmental QAPI meetings."

2. Review of the MEC minutes for January 2013 to present revealed the only members who regularly attended the meetings were members of the medical staff, the Chief Executive Officer (CEO), Chief Operations Officer (COO), the Director of Quality, and the Director of Nursing (DON). The pharmacist attends the MEC meetings once each quarter.

3. Review of QAPI committee meeting minutes for 2014 revealed no evidence that all hospital departments and services participated in measuring, analyzing, and tracking of quality indicators. There was no evidence found to show the Emergency Department (ED) actively participates in the QAPI process.

4. During an interview conducted on 10/16/14 at 1000 with the Chief Operating Office (COO), she stated, "Every department does QA". After reviewing the minutes from the MEC and QAPI Committee, as listed above, the COO confirmed that there was no documentation to indicate that all departments participate in the QAPI program.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review and staff interview it was determined that quality assurance failed to measure, analyze and track quality indications which were developed as a result of hospital specific evidence, peer related research or information received from their quality improvement organization. (QIO). Additionally, there were no actions or recommendations made as a result of any data provided from quality indicator projects. When there is not an effective and comprehensive Quality program based on hospital priorities or information from the QIO can result in missed opportunities to improve patient care and safety with possible negative patient outcomes.

Findings include:

Review of the Quality Assurance and Performance Improvement (QAPI) Plan for 2014 states in part the following:

"The West Virginia Department of Health and Human Resources (WVDHHR), the Medical Executive Committee (MEC) and hospital Administration will support and dedicate appropriate resources to establish, implement and continually provide for the performance measurement, assessment and improvement of activities related to patient care and customer satisfaction."

The Director of QAPI oversees the coordination of the QAPI program. The Medical Executive Committee (MEC) is delegated the primary authorization over activities related to functions of quality assessment and performance improvement. QAPI activities include how the hospital designs, measures, assess and improves important processes.

The MEC will recommend all performance improvement teams (PITs) to address performance issues which require a multidisplinary, multidepartmental approach. The hospital will have at least two functioning PITs per year. Minutes from PITs will be presented to the Director of QAPI for presentation at the MEC.

Review of the MEC committee minutes for 2013 to present revealed there is a performance improvement team (PIT) working on medication safety and critical timing of medications. There is also a team working on Clostridium Difficle. Also discussed in meetings was a Surgical Care Improvement Project (SCIP).

These MEC committee minutes lacked discussion and approval for the quality indicators the QA program has selected and the reasons these indicators were selected relative to hospital specific evidence, peer related information or information from quality improvement organization.

Further review of the monthly MEC committee reports from January 2013 to September 2014 revealed there was no documentation the group made any decisions, took action or made any recommendations for process changes or other health care improvement changes. The meetings routinely documented action taken was to approve committee minutes/reports, policies, formulary changes, appointment of medical staff members and a reference that substantiated complaints were addressed in an appropriate manner. The only specific action taken was:

1. Add Lactinex and yogurt to dietary trays.
2. Have utilization review track surgical care improvement failures by physicians and report findings.
3. For patients who are transferred to the emergency department from another clinic there must be communication between physicians.
4. Requirement that all physicians are to put an order in for all radiological exams and order a three (3) view on all extremity exams.
5. In July 2014 the committee reviewed a sentinel event and recorded "Sentinel Event reviewed and action plan discussed." (There was no documentation of what the action plan was, or if there were any process/policy changes made as a result of the review).

The Chief Operations Officer (COO) and the Quality Manager were both interviewed on 10/16/14 at 11:10 AM. The COO said the Medical Executive Committee (MEC) has the authority for the Quality Assurance Program and these meetings occur on a monthly basis. When questioned as to who determines the quality indicators or projects she said hospital staff, departments or the MEC committee can identify and initiate a project. She stated there is a hospital wide project for Clostridium Difficle for 2014.

The COO and Director of Quality were asked to review the MEC committee minutes from 2013 to present. The COO agreed the meetings lacked analysis of reports which were presented. Also, she agreed there was no documentation of recommendations for health care process changes with monitoring and reporting requirements to the committee. She also concurred there was no documentation the MEC committee discussed and approved the quality indicators the QA program are using and the reasons these indicators were selected.