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. 22, 2014 |
| VIOLATION: COMPLIANCE WITH 489.24 | Tag No: A2400 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on review of records and interviews with staff, it was determined the hospital failed to comply with 489.24 by not providing a medical screening examination in two (2) of twenty-four (24) cases reviewed (patients #1 and 12). Cross refer to A2406. B. Based on review of records and written policies and interviews with staff, it was determined the hospital failed to enforce written policies which ensure the hospital complies with 489.24 relative to the triage process and the monitoring of patients who have been triaged and have not been taken into the Emergency Department (ED) for a medical screening examination. This was noted in four (4) of six (6) cases reviewed for patients who received a triage assessment and then eloped from the hospital without receiving a medical screening examination (patients #10, 21, 22 and 23). This has the potential for patients to have inadequate monitoring while they are awaiting a medical screening examination. Findings include: 1. Review of hospital policy "Vital Signs and Assessment", last revised 1/11, states "All patients not taken directly to a treatment area will be reassessed with a full set of vital signs every ninety (90) minutes or sooner, at the discretion of the nurse, until moved into a treatment room." Review of the medical record for patient #10 revealed the thirty-two (32) year old female patient (MDS) dated [DATE] at 9:21 p.m. The triage assessment was done at 9:55 p.m. and the chief complaint included "hit by a coal truck, head hurting, need checked, lip stitches." There are no other notes or documentation of a reassessment of the patient. The ED log lists the time the patient left was 1:00 a.m., three (3) hours and five (5) minutes after the initial triage assessment. Review of the medical record for patient #21 revealed the forty (40) year old male patient (MDS) dated [DATE] at 1:56 p.m. The patient was triaged at 2:10 p.m. and the chief complaint included "Right lower quadrant (abdominal) pain, states pain one (1) week worse yesterday, current pain 10". The only other notes written were when the patient was called to the ED at 9:45 p.m., 10:00 p.m. and 10:15 p.m. when it was discovered the patient had eloped. There were no rechecks of the patient documented between 2:10 p.m. and 9:45 p.m., seven (7) hours and thirty-five (35) minutes after the triage assessment. Review of the medical record for patient #22 revealed the fifty-two (52) year old male patient (MDS) dated [DATE] at 10:34 pm. The patient was triaged at 10:34 p.m. and the chief complaint included "shortness of breath X three (3) days and pain in the right side X three (3) days, pain level 7". The ED log listed the patient eloped at 3:10 a.m., four (4) hours and thirty-six (36) minutes after the triage assessment. There were no documented rechecks of the patient after the triage assessment. Review of the medical record for patient #23 revealed the fifty-four (54) year old male patient (MDS) dated [DATE] at 11:10 a.m. The patient was triaged at 11:15 a.m. and the chief complaint included "complains of pain right side due to fall, caused lung collapse on 3/9/2014 treated with chest tube, (chest tube) removed 3/16/2014, pain 10". The patient was called to the ED at 2:26 p.m. and was discovered to have eloped, three (3) hours and eleven (11) minutes after the triage assessment. There were no documented rechecks of the patient after the triage assessment. These records were reviewed with the DON and the Director of Quality Improvement on 10/22/2014 starting at 11:00 a.m. and they concurred with the findings. C. Based on interview, it was determined the hospital failed to ensure the Emergency Department (ED) participates in the hospital wide Quality Assessment and Performance Improvement (QAPI) activities to ensure there is compliance with 489.20 and 489.24 and to ensure quality of care is provided to all patients. This has the potential for patients presenting to the ED to have poor quality of care and/or poor outcomes when there is no on-going assessment of the quality of care provided and systems in place to improve care. Findings include: The DON and the Director of Quality Improvement were interviewed jointly on 10/22/2014 starting at 11:00 a.m. relative to quality issues in the ED such as patients leaving without treatment, leaving against medical advice (AMAs), and transfers to other acute care facilities, as an example. The Director Quality Improvement confirmed reports of patients leaving before the medical screening examination are being recorded as a "number" only and those cases are not routinely investigated to ensure all policies are being followed. The DON confirmed the "time studies" of the time increments between the time patients present to the ED, are triaged, placed in a treatment bed, examined by the physician, and then admitted are also only being recorded as a "number" only on the average, and there is no other investigation done to ensure all cases falling outside an expected criteria or thresh hold are being cared for in accordance with hospital policy. They both stated the ED is monitoring some issues as a department, but the ED has not reported to or participated in the hospital wide QAPI activities at least since January 2014. |
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| VIOLATION: EMERGENCY ROOM LOG | Tag No: A2405 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record and interviews, it was determined the hospital failed to appropriately enter the patient's name and information on the Emergency Department (ED) log and failed to document the information gathered during the ED Registered Nurse (RN) triage assessment for one (1) of twenty-four (24) records reviewed (patient #1). This has the potential for the hospital to miss opportunities for improvement when patients are not logged and tracked after they are seeking a medical screening examination. There is also a potential for patients to not receive an appropriate medical screening examination when information gathered in the nursing triage assessment is not conveyed to the physician provider in the ED. Findings include: Review of available information relative to patient #1 revealed the patient was brought to the hospital on [DATE] for screening for on ongoing problems in her genital area. The patient initially presented to the Rural Health Clinic (RHC) which is located inside the hospital. The Licensed Practical Nurse (LPN) completed the "Rural Health Clinic Registration Form" and documented the patient was signed in at 4:35 p.m. The patient was noted to be two (2) years old and the chief complaint was documented as "Stiffens when diaper is changed, diaper wipes used, ointment (when need) is applied, bottom and genital area is washed. Social worker advised examination." The "Registration Complaint" was listed as "Vaginal irritation" by the LPN. On the RHC visit note, the LPN documented "Reason for Visit" as "Complains of child grabbing at groin area, having pain even when wiped, social work advised exam, grandmother received children in January." The patient's vital signs were recorded. There were no other notes to review. The Director of Nursing (DON) confirmed during interview on 10/20/2014 at 9:40 a.m., there were no visit notes other than the notes written by the clinic LPN. The DON stated during the same interview the patient was initially seen in the RHC. He stated the RHC physician refused to see and examine the patient and he instructed the LPN to take the patient to the ED to have an examination. Review of the ED log for 3/7/2014 revealed the patient was not listed on the log. The ED triage RN who was working on 3/7/2014 was interviewed on 10/22/2014 at 2:00 p.m. The DON was present during the interview with the triage nurse. The triage nurse stated the RHC LPN brought the patient and her grandmother to the ED triage area on 3/7/2014 and the LPN stated the patient needed a rape kit for an alleged sexual assault that occurred two (2) months earlier. The triage nurse stated she explained to the grandmother they can't really collect evidence after ninety-six (96) hours (after an alleged assault). She stated the grandmother stated there were no visible tears or scarring on the two (2) year old's bottom. The nurse stated she felt it would be too traumatic to examine the two (2) year old if nothing was visible or evident of abuse. She stated she told the grandmother there was really no use to examine patient if there was no apparent evidence. She also stated she felt she did the right thing by educating the grandmother about the rape kit. She finally stated she hated for the patient and grandmother to wait as it was "really busy that day". She stated the patient was not "an urgent case" and they would have to wait awhile to be seen." She stated the grandmother left the hospital with the patient. A final review of the available record and related documentation was reviewed with the DON and the Director of Quality Improvement on 9/22/2014 at 12:00 noon, and they concurred the patient was not listed on the ED log for the date of the visit, nor was there a triage note written by the RN for the patient's visit. |
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| VIOLATION: MEDICAL SCREENING EXAM | Tag No: A2406 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and interviews, it was determined the hospital failed to provide a medical screening examination for 2 of 24 patients reviewed who presented to the Emergency Department and requested treatment (patients #1 and 12). This has the potential for patients not receiving appropriate care and services. Findings include: 1. Review of available information relative to patient #1 revealed the patient was brought to the hospital on [DATE] for screening for on ongoing problems in her genital area. The patient initially presented to the Rural Health Clinic (RHC) which is located inside the hospital. The RHC Licensed Practical Nurse (LPN) completed the "Rural Health Clinic Registration Form" and documented the patient was signed in at 4:35 p.m. The patient was noted to be two (2) years old and the chief complaint was documented as "Stiffens when diaper is changed, diaper wipes used, ointment (when needed) is applied, bottom and genital area is washed. Social worker advised examination." The "Registration Complaint" was listed as "Vaginal irritation" by the LPN. On the RHC visit note, the LPN documented "Reason for Visit" as "Complains of child grabbing at groin area, having pain even when wiped, social work advised exam, grandmother received children in January." The patient's vital signs were recorded. There were no other notes to review. The DON confirmed during interview on 10/20/2014 at 9:40 a.m., there were no visit notes other than the notes written by the clinic LPN. He confirmed there were no notes relative to the visit written by any ED nursing or medical staff. The DON stated during the same interview the patient was initially seen in the RHC. He stated the RHC physician refused to see and examine the patient and he instructed the LPN to take the patient to the ED to have an examination. Review of the ED log for 3/7/2014 revealed the patient was not listed on the log. The ED triage RN who was working on 3/7/2014 was interviewed on 10/22/2014 at 2:00 p.m. She stated the LPN brought the patient and her grandmother to the ED triage area on 3/7/2014 and the LPN stated the patient needed a rape kit for an alleged sexual assault that occurred two months earlier. The triage nurse stated she explained to the grandmother they can't really collect evidence after ninety-six (96) hours (after an alleged assault). She stated the grandmother stated there were no visible tears or scarring on the two (2) year old's bottom. The nurse stated she felt it would be too traumatic to examine the two (2) year old if nothing was visible or evident of abuse. She stated she told the grandmother there was really no use to examine patient if there was no apparent evidence. She also stated she felt she did the right thing by educating the grandmother about the rape kit. She finally stated she hated for the patient and grandmother to wait as it was "really busy that day". She stated the patient was not "an urgent case" and they would have to wait awhile to be seen." She stated the grandmother then left the hospital with the patient. A final review of the available record and related documentation was reviewed with the DON and the Director of Quality Improvement on 10/22/2014 at 12:00 noon, and they concurred a medical screening examination was not provided to the patient. 2. Record #12 was chosen from the ED log for May 2014. The patient was entered on the log as a thirteen (13) year old female with "psych issues" listed as the diagnosis and the disposition was "discharged to home." Review of the record revealed the patient signed in on 5/27/2014 at 11:23 a.m. The chief complaint was listed as "Welfare said to bring her out here for a psych test." The ED RN wrote an entry at 12:05 p.m., in the medical record which stated in part "(ED physician) spoke with grandmother in his office with myself being present about issues with patient. Grandmother stated patient threatened to kill herself at school on Friday and was informed by the school that she needed to take patient to speak with Child Protective Services (CPS) about patient's problems. CPS referred her to the ED for psychiatric evaluation. (ED physician) informed grandmother that we only offer medical evaluation not psychiatric evaluations. Grandmother voiced understanding. I did contact Southern Highlands (community mental health) to try to set up appointment for patient to have a psychological evaluation. However the office in Welch does not take children..." At 1:10 p.m., the nurse documented "Spoke with grandmother informing her of progress process (sic) and gave her phone numbers of mental health facilities that specialized in children. I asked patient again if she had thoughts of hurting herself and she denied that she wanted to hurt herself or anyone else. Grandmother stated she would follow up with the "Stop the Hurt" organization and see if they might be able to help patient. Informed patient we would be happy to evaluate patient and grandmother stated if we could not do a mental evaluation she did not need to stay...Grandmother refused further evaluation and left with patient." On the physician documentation sheet, the physician wrote notes about his conversation with the patient's grandmother. There was no note by the physician about an examination of the patient. On the demographic sheet, a hand written note was added at the bottom that stated "Not seen by ED physician." The record was reviewed with the Director of Nursing and the Director of Quality Improvement on 10/22/2014 at 12:00 p.m. They stated they were familiar with the case. They concurred the patient was never given a medical screening examination during the visit. The Director of Nursing stated "we can't do a psychological evaluation here". When questioned how patients are usually treated when they do have psychological issues, he stated "They are given a medical screening and transferred to a facility that can do a psychological evaluation." Both the DON and the Director of Quality Improvement concurred the patient should have received a medical screening examination by the ED physician. |
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