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 Nov. 18, 2015
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation and staff interview it was determined the hospital failed to maintain a current biomedical equipment contract to ensure equipment was maintained in a safe operating manner. This deficient practice resulted in a failure to ensure care was provided in a safe setting and has the potential to adversely impact all patients.

Findings include:

1. During the course of the physical environment tour conducted throughout the first day of the survey on 11/16/15 it was determined multiple pieces of medical equipment, including equipment in use in the surgical suite, were not being serviced and maintained per an established schedule. This resulted in a determination of Immediate Jeopardy on 11/16/15.

2. The Chief Operating Officer acknowledged throughout the course of the survey there was no current contract for preventative maintenance of biomedical equipment. He stated at 4:50 p.m. on 11/18/15 that reestablishing a contract for maintenance of medical equipment was a priority.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review, document review and staff interview it was determined the hospital failed to ensure performance improvement activities tracked and analyzed all adverse events. This deficient practice was identified in one (1) of one (1) records reviewed in which cancellation of a surgical procedure occurred due to failure of anesthesia equipment (patient #9). This failure has the potential to adversely impact all patients.

Findings include:

1. Review of the 7/30/15 Operating Room (OR) log revealed patient #9 had a case canceled due to an anesthesia machine. Review of the medical record revealed the patient was intubated at 8:20 a.m. and extubated at 9:15 a.m. The record reflected the case was canceled due to failure of the anesthesia machine.

2. Review of the incident log for July and August 2015 revealed there was no documentation related to this incident.

3. The Incident Reporting (rev. 7/11), Procedure for Completion of Welch Community Hospital (WCH) Incident Report Policy (rev. 7/11) and Sentinel Event (5/12) policies were provided for review. The Incident Policy states, in part: "An incident is defined as any happening not consistent with the normal or usual operation of the hospital or department..."

The Sentinel Event Policy states, in part: "A sentinel event is an adverse event of a severe and urgent nature that can result in an unexpected and undesirable patient outcome..."

Review of the Procedure For Completion of the WCH Incident Report revealed, in part: "Complete the Incident Report in it's entirety...Supervisor to be given the Incident Report immediately after occurrence..."

4. An interview was conducted with the Director of Quality Improvement/Risk Manager at 9:15 a.m. on 11/18/15. She confirmed there was no documentation of the event sent to the Quality Department and she was not aware of the incident. She also acknowledged that most hospital departments are under reporting incidents.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined the hospital failed to ensure the Obstetrical (OB) Unit was staffed with nurses who maintain current Neonatal Resuscitation certification as required. This deficient practice was identified in fourteen (14) of fourteen (14) nurses on the OB schedule (Registered Nurses #1, 2, 3 and 4; Licensed Practical Nurses #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10). This failure has the potential to adversely impact the care and condition of all newborns in the department.

Findings include:

1. The current OB schedule was provided for review. There were four (4) Registered Nurses (RN) and ten (10) Licensed Practical Nurses (LPN) on the schedule. Review of the schedule revealed one (1) RN and one (1) LPN are on duty each time the department is open.

2. Review of the current job description for OB RN revealed the following, in part, under 'Qualifications': "Successful completion of neonatal resuscitation certification..."

3. An interview was conducted with the OB Nurse Manager at 8:20 a.m. on 11/18/15. She stated that all OB nurses, LPNs and RNs, are expected to maintain current certification in Neonatal Resuscitation. A request was made for the dates of the last certification for all OB nurses. She stated that most nurses had been certified previously but most had expired in February 2015. She stated she was in the process of scheduling a recertification class.

4. A record of neonatal certification for OB staff was provided at 10:15 a.m. on 11/18/15. Review of the record revealed certification of RN 2 and RN 3 expired on [DATE]. LPN 1, 2, 3, 6, 9 and 10 also expired on [DATE]. The Manager confirmed there was no record the rest of staff had been certified. She stated the process for certification recently changed which resulted in a delay in obtaining the training for the department.
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined the hospital failed to ensure the Dietary Manager was responsible for maintaining departmental policies and visiting patients (per job description) to discuss diets and food likes/dislikes, for eight (8) of eight (8) current patients with tray cards (patients # 1, 2, 3, 4, 5, 6, 7 and 8). This failure creates the potential for an adverse impact on the nutritional status of all patients.

Findings include:

1. A request was made for the procedure and/or policy for making dietary substitutions. At 1:05 p.m. on 11/17/15 the Dietary Manager stated there was no formal policy for making substitutions. She stated she visits all patients and documents special needs and likes/dislikes on the tray card. Staff uses the tray card to make substitutions from an established list. A request was made for the tray cards for current patients. She provided copies of tray cards for patients # 1, 2, 3, 4, 5, 6, 7 and 8. None of the tray cards had any food allergies or likes/dislikes recorded.

When asked if she had seen all of the above noted patients, the Dietary Manager acknowledged she had not seen any of the patients yet. It was noted that patient #2 was an eighty (80) year old who was admitted on [DATE], twelve (12) days earlier, with a diagnosis of anorexia.

The policy and procedure manual for the Dietary Department was requested. At 1:50 p.m. on 11/17/15 the Dietary Manager provided a manual which had not been approved by the Dietician or medical staff. She acknowledged the Dietary Manual was incomplete. She stated the manual was found to have gone missing in December 2014 and she was working on recreating the manual.

2. The current job description for the Dietary Manager was provided for review. It notes, in part: "Job Summary: Revise and update job descriptions, policies and procedures...Do diet consults for residents, inpatients and outpatients with advice/aid of Dietician..." Under 'Responsibilities and Duties: Manage the Dietary Department as follows', it states, in part: "Ensure that each employee follow policies and procedures and advise employees of changes in policies and procedures as they occur...Visit residents and patients discussing diets, food likes and dislikes..."

3. At 11:05 a.m. on 11/18/15 an interview was conducted with the Dietician. She stated she usually spends one (1) day a week at the hospital. The above issues were discussed with her and the Dietary Manual was reviewed. She acknowledged the Manual was not complete and stated she was not always aware of problems in the department. She stated the identified issues would be corrected.
VIOLATION: THERAPEUTIC DIET MANUAL Tag No: A0631
Based on document review, observation and staff interview it was determined the hospital failed to maintain a current therapeutic diet manual approved by the dietician and medical staff and ensure the manual is readily available to medical and nursing staff. This failure creates the potential for an adverse impact on the nutritional status of all patients.

Findings include:

1. The Fall/Winter Blue Print Diet Extensions 'special diet' manual was provided by the Dietary Manager for review. Review of the special diet manual revealed no indication the manual was approved by the Dietician or medical staff.

2. At 1:05 p.m. on 11/17/15, the special diet manual was reviewed and discussed with the Dietary Manager. She stated the Fall/Winter menus were implemented on 11/1/15. She confirmed the Dietician had not yet approved the diet manual. She also confirmed the medical staff had not approved the manual.

3. At 11:05 a.m. on 11/18/15 an interview was conducted with the Dietician. She stated she usually spends one (1) day a week at the hospital. The 'special diet' manual was reviewed and discussed with her. She acknowledged that neither she nor any medical staff had approved the manual. She stated this would be corrected and special diet manuals would be placed on nursing units.

4. A tour of the nursing units was conducted between 1:05 p.m. and 1:35 p.m. on 11/18/15 in order to determine if nursing staff had access to special diet manuals, and no special diet manuals were located:

At 1:05 p.m. in the Medical Surgical Unit, Registered Nurse #1 stated dietary takes care of everything and agreed the unit had no special diet manual.

At 1:10 p.m. in the Intensive Care Unit, the Charge Nurse stated the unit had no special diet manual.

At 1:35 p.m. in the Obstetrical Unit the Nurse Manager stated the unit had no special diet manual.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations and staff interview it was determined facility failed to maintain its physical environment in a safe, clean and orderly fashion.

Findings include:

1. Observation of the second floor on 11/16/15 at 2:30 p.m. revealed forty-seven (47) of fifty-four (54) operational windows did not have window screens, or were not secured, to prevent being opened and allowing insects to enter the facility.

2. On 11/16/15 at 2:35 p.m., the above findings were discussed with the Maintenance Supervisor and he agreed the windows did not have screens, or were not secured, to prevent opening.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on document review and staff interview it was determined the hospital failed to assure the designated infection control director was qualified through education, training, experience or certification. This failure creates the potential for an adverse impact on the quality of infection control practices which can negatively impact all patients.

Findings include:

1. The personnel file for the Infection Control (IC) Director was requested and provided for review at approximately 12:30 p.m. on 11/17/15. Review of the file revealed she was hired for the infection control position in June 2014. The file revealed she had no experience in infection control and contained no documentation of education, training or certification in infection control.

2. An interview was conducted with the IC Director at 9:38 a.m. on 11/18/15. She confirmed she had no infection control experience prior to hire and had received no ongoing education or training since that time.

3. An interview was conducted with the Director of Nursing at 11:25 a.m. on 11/18/15. He acknowledged the IC Director had no infection control experience when hired and had received no education or training since.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observation and staff interview it was determined the hospital failed to implement and maintain the biomedical equipment inspection and testing program to prevent, recognize and control defective patient care equipment within the facility and failed to ensure preventative maintenance and inspection was conducted by a reliable BioMedical company or individual.

These failures resulted in an Immediate Jeopardy (IJ) to the health and well-being of all operating room patients. The IJ was first called at 4:50 p.m. on 11/16/15. The hospital had continued non-compliance with biomedical equipment testing practices until 11/16/15 at 5:48 p.m. At that time, the hospital was informed that surgeries must cease until biomedical equipment within the operating room had been tested and recertified by a reliable BioMedical company or individual. The IJ was abated upon the cessation of surgeries.

Findings include:

1. During observation on 11/16/15 between 3:00 p.m. and 4:30 p.m., it was discovered that thirty-nine (39) of forty-three (43) pieces of biomedical equipment in surgery was found to be out of date for annual maintenance. Two (2) pieces of equipment expired in March 2015 and thirty- seven (37) pieces expired in September 2015.

2. The above findings were discussed with the Chief Executive Officer on 11/16/15 at approximately 4:30 p.m. and he agreed the biomedical equipment was out of date and at the time of the survey, the facility did not have a biomedical agreement or contract to have the equipment serviced.
VIOLATION: INFECTION CONTROL OFFICER(S) Tag No: A0748
Based on document review and staff interview it was determined the facility failed to ensure the designated Infection Control Director was qualified through education, training, experience or certification. This failure creates the potential for an adverse impact on the quality of infection control practices, which can negatively impact all patients.

Findings include:

1. The personnel file of the Infection Control Director was reviewed on 11/18/15. It revealed the director's hire date for her current position as 6/2014. No documentation was found of prior experience in infection control, training for the position, education since assuming the position or certification in infection control.

2. An interview was conducted with the Infection Control Director on 11/18/15 at 10:25 a.m. She confirmed she had no prior experience in infection control at the time she assumed the position, and also confirmed she had not received any training, ongoing education or certification in infection control since that time.

3. An interview was conducted with the Chief Nursing Officer on 11/18/15 at 11:25 a.m., at which time he concurred with the above findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review, observation and staff interview it was determined the hospital failed to ensure proper gloving technique when performing glucose monitoring, per facility policy. This failure has the potential for patient harm due to cross contamination.

Findings include:

1. Facility policy entitled, "Specific Use of Personal Protective Equipment", last reviewed 1/11, states, in part: "Employees shall wear gloves when it can be reasonably anticipated that the employee may have hand contact with blood."

2. An observation of the medical surgical unit was conducted on 11/17/15 at 10:50 a.m. Licensed Practical Nurse (LPN) #1 was observed donning one (1) glove on the right hand. She then grasped the patient's finger with the left, ungloved hand, cleansed it with an alcohol swab, used the right hand to perform the puncture then used her ungloved hand to place a cotton ball on the bleeding site.

3. An interview was conducted with LPN #1 on 11/17/15 at 10:56 a.m. at which time she stated, "I always use one (1) glove. I know I should use two (2) gloves."
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document review and staff interview it was determined the facility failed to ensure there was an effective Governing Body that carried out the functions of maintaining necessary contractual agreements for the maintenance of biomedical equipment (See tag A 083).
VIOLATION: CONTRACTED SERVICES Tag No: A0083
Based on document review and staff interview it was determined the Governing Body of the hospital failed to ensure contracted services were provided for the periodic inspection and maintenance of the biomedical equipment. This failure has the potential to result in serious patient harm when electrical equipment used for patient care is not properly inspected and maintained.

Findings include:

1. Review of the current "ByLaws of the Governing Body of Welch Community Hospital" revealed members of the Governing Body include the Chief Executive Officer (CEO), Chief Operations Officer (COO), Chief Nursing Officer (CNO), the Chief Financial Officer (CFO) and the Director of Quality and Risk Management (DQRM). The ByLaws stated, in part: "The Governing Body will hold the CEO accountable for the application and implementation of established policies to the operation of the hospital..."

2. Review of the document entitled, "Master Agreement", with order number CMA 0506 2845 WEH and order date 12/5/14, for "Medical Equipment Maintenance and Repairs" revealed the contractual agreement had an effective end date of 7/18/15.

3. Review of the Nursing Council meeting minutes, dated 7/27/15, revealed the CNO was in attendance and that the BioMedical contract had expired.

4. During an interview with the CEO on 11/16/15 at approximately 4:30 p.m., he stated he was aware the BioMedical provider's contract had expired and that there was no current contract with any qualified BioMedical inspection individual/company.

5. The expired BioMedical contract was discussed with the CNO and the COO during a joint interview on 11/17/15 at approximately 10:25 a.m. and they both concurred they were aware the hospital did not have a current contract with a qualified BioMedical individual or company.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on record review, document review and staff interview it was determined the hospital failed to document, per policy, the analysis of an incident in which there was equipment failure while a patient was under general anesthesia. This deficient practice involved one (1) of two (2) patients reviewed who had equipment fail while under general anesthesia (patient #11). This failure creates the potential for an adverse impact on the quality of care for all patients who undergo general anesthesia at the facility.

Findings include:

1. Review of the medical record for patient #11 revealed the patient was scheduled for a surgical procedure under general anesthesia on 7/30/15. Documentation in the anesthesia record revealed the patient was already sedated and intubated when a malfunction in the anesthesia machine was discovered. The patient was awakened from anesthesia and extubated. The surgical procedure was canceled and the patient was admitted to the hospital.

2. Review of the hospital policy entitled, "Incident Reporting", last revised 7/11, revealed it stated, in part: "The Incident Report is to be completed immediately after the incident by the individual who has the best knowledge of the incident...If a piece of equipment is involved, the name of the equipment, the manufacturer, ...and other related identification should be documented on the incident report...The supervisor has the responsibility to forward all incident reports...to the QA&I Coordinator...The Safety Committee will follow-up on all...safety incidents to formulate findings, make recommendations and to implement the action, follow-up, along with the Department Manager."

3. The Incident Report log for 2015 was reviewed and no documentation was found to indicate that an incident report had been completed for the above-stated event, as required by hospital policy.

4. Review of the Safety Committee meeting minutes for May through October 2015 revealed there was no documentation related to follow-up on any safety incidents during those time periods.

5. During a telephone interview with the Certified Registered Nurse Anesthetist (CRNA) on 11/17/15 at 3:15 p.m., she stated she recalled the case involving patient #11. She stated, "We put her to sleep, but canceled the case due to a malfunction on the (anesthesia machine) monitor." The CRNA stated she called the manufacturer and he advised her the problem was a battery and recommended canceling the case. She stated she thought she had completed an incident report about the event and "handed it to (the surgery supervisor)" but was not certain. The CRNA stated she had no further follow-up with patient #11 after she was moved from the surgery department.

6. The Incident Log was reviewed with the Director of Quality and Risk Management during an interview on 11/17/15 at approximately 3:30 p.m. and she agreed there was no record that an incident involving patient #11 had been reported, as per hospital policy.