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.

WILLIAMSON MEMORIAL HOSPITAL 859 ALDERSON STREET WILLIAMSON, WV 25661 Aug. 7, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, document review and staff interviews it was determined the hospital failed to ensure care was being provided in a safe setting for five (5) (patient #1, 2, 3, 4 and 5) out of thirteen (13) patients who were ordered telemetry monitoring. The telemetry monitoring system was non-operational and the five (5) patients were observed on portable bedside heart monitors which were not attached to a central monitoring system. Three (3) of the five (5) patients were observed to have the door to their rooms shut limiting the alarm sounds which could be heard. This failure has the potential to result in serious injury and/or harm if a medical emergency should occur (See Tag A 144).

A. An immediate jeopardy (IJ) to patient rights (Care in a Safe Setting) was called on 8/5/19 at 1:57 p.m. as patients ordered telemetry were observed to be on portable bedside heart monitors with no central telemetry monitoring system attached to the heart monitors.

B. Harm or Potential Harm: The heart monitors attached to these patients were not observed continuously. They were being observed every fifteen minutes. Alarms were set but three (3) of the five (5) patients were observed to have the door to their room shut limiting the sound of any alarm which may sound during a medical emergency.

C. Immediacy: The likelihood of serious harm or death to occur to patients should a lethal arrhythmia occur without the patients on the portable heart monitors being continuously monitored was extremely high. Patients #3 and #5 were directly observed on bedside heart monitors without central telemetry continuous monitoring. The door to patient #5's room was shut. The alarm on the bedside monitor was observed to not be loud enough to hear at the nurse's station. An interview conducted with the Nursing Manager of the Medical Surgical Unit revealed patients #1, #2 and #4 were also being monitored on portable beside heart monitors which were not attached to a central monitoring system. The doors to the rooms for patient #1 and #2 were also observed to be shut. The Intensive Care Unit (ICU) did not have patients. While checking to see if the patients could be transferred to the ICU for monitoring it was revealed six (6) of six (6) bedside monitors in ICU were due for maintenance 6/19 and had not been completed.

D. Culpability: An interview was conducted with the Chief Nursing Officer on 8/5/19 at approximately 1:40 p.m. She stated the telemetry central monitoring system had been down for a couple of months.

E. An immediate plan of correction was received and sent to the State Agency Program Manager. It was accepted and the facility abated the IJ on 8/5/19 at 5:33 p.m.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review, staff interviews and observation it was revealed the hospital failed to provide care in a safe setting for five (5) out of thirteen (13) patients on the Medical Surgical Unit (MSU) by not providing a central monitoring system for patients ordered telemetry. Equipment used for heart monitoring on both the MSU and Intensive Care Unit (ICU) was out of date and the facility did not have cartridges used for performing arterial blood gases (ABGs) on patients #1, 2, 3, 4 and 5. ABG specimens were being sent to another location for completion. This failure has the potential to affect all patients requiring telemetry monitoring, intensive care monitoring and the return of emergency results for arterial blood gases.

Findings include:

1. A review of the hospital policy titled Telemetry Monitoring Utilization with an approval date of 10/26/16 revealed in part: "According to the American College of Cardiology there are several guidelines that must apply to the use of cardiac monitoring in all clinical settings. Adequate human surveillance of the monitors 24 hours per day ..."

2. A review of the hospital policy titled Clinical Alarm Management with an effective date of 10/16 revealed in part: "Alarm volume levels must be maintained at an easily audible level at all times by monitor technician and/or clinical patient care staff."

3. An interview conducted with the Chief Nursing Officer on 8/5/19 at approximately 1:40 p.m. revealed the central telemetry monitoring system had been non-operational for two (2) months.

4. An interview conducted with the Director of Radiology and Respiratory Therapy on 8/6/19 at approximately 2:40 p.m. revealed the arterial blood gas (ABG) machine was working but would reach end of life in 2020. ABGs could not be done on site because they did not have the measurement cartridges needed to do the ABGs. ABG samples had been sent off site for completion starting on 7/31/19. There was not a written policy or procedure for sending the ABGs off site for processing. The Director of Radiology and Respiratory Therapy concurred with these findings during the interview.

5. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed five (5) (patient #1, 2, 3, 4 and 5) out of thirteen (13) patients on portable bedside heart monitors which were not attached to a central monitoring system.

6. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed three (3) (patients #1, 2 and 5) out of five (5) patients on the portable bedside heart monitors had the door to their room closed limiting the sound of the alarms.

7. A tour of the ICU on 8/5/19 at approximately 1:45 p.m. revealed six (6) out of six (6) bedside heart monitors were due to have planned maintenance 6/19 and had not been completed.

8. A tour of the MSU on 8/6/19 at approximately 9:20 a.m. revealed there were seven (7) portable heart monitors and three (3) of the monitors were past due for maintenance. Two (2) monitors were due for maintenance 1/19 and one (1) monitor was due for maintenance 6/19.

9. An interview was conducted with the Chief Nursing Officer on 8/6/19 at approximately 9:20 a.m. and she concurred with these findings.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on document review, staff interviews and observation it was revealed the hospital failed to provide adequate supplies and equipment for five (5) (patients #1, 2, 3, 4 and 5) out of thirteen (13) patients on the Medical Surgical Unit (MSU) by not providing a central monitoring system for patients ordered telemetry. Equipment used for heart monitoring on both the MSU and Intensive Care Unit (ICU) was out of date. This failure has the potential to affect all patients requiring telemetry monitoring and/or intensive care monitoring.

Findings include:

1. A review of the hospital policy titled Telemetry Monitoring Utilization with an approval date of 10/26/16 revealed in part: "According to the American College of Cardiology there are several guidelines that must apply to the use of cardiac monitoring in all clinical settings. Adequate human surveillance of the monitors 24 hours per day ..."

2. A review of the hospital policy titled Clinical Alarm Management with an effective date of 10/16 revealed in part: "Alarm volume levels must be maintained at an easily audible level at all times by monitor technician and/or clinical patient care staff."

3. An interview conducted with the Chief Nursing Officer (CNO) on 8/5/19 at approximately 1:40 p.m. revealed the central telemetry monitoring system had been non-operational for two (2) months.

4. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed five (5) (patients #1, 2, 3, 4 and 5) out of thirteen (13) patients on portable bedside heart monitors which were not attached to a central monitoring system.

5. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed three (3) (patients #1, 2 and 5) out of the five (5) patients on the portable bedside heart monitors had the door to their room closed limiting the sound of the alarms.

6. A tour of the ICU on 8/5/19 at approximately 1:45 p.m. revealed six (6) out of six (6) bedside heart monitors were due to have planned maintenance 6/19 and had not been completed.

7. A tour of the MSU on 8/6/19 at approximately 9:20 a.m. revealed there were seven (7) portable heart monitors and three (3) of the monitors were past due for maintenance. Two (2) monitors were due for maintenance 1/19 and one (1) monitor was due for maintenance 6/19.

8. An interview was conducted with the CNO on 8/6/19 at approximately 9:20 a.m. and she concurred with these findings.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on document review, staff interviews and observation it was revealed the hospital failed to maintain an environment to ensure the safety for five (5) out of thirteen (13) patients on the medical surgical unit (MSU) by not providing a central monitoring system for patients ordered telemetry or for patients in the Intensive Care Unit (ICU) as equipment used for heart monitoring on both the MSU and ICU was out of date. The facility also did not have cartridges used for performing arterial blood gases (ABGs) (patients #1, 2, 3, 4 and 5). ABG specimens were being sent to another location for completion. This failure has the potential to affect all patients requiring telemetry monitoring, intensive care monitoring and the return of emergency results for arterial blood gases.

Findings include:

1. A review of the hospital policy titled Telemetry Monitoring Utilization with an approval date of 10/26/16 revealed in part: "According to the American College of Cardiology there are several guidelines that must apply to the use of cardiac monitoring in all clinical settings. Adequate human surveillance of the monitors 24 hours per day ..."

2. A review of the hospital policy titled Clinical Alarm Management with an effective date of 10/16 revealed in part: "Alarm volume levels must be maintained at an easily audible level at all times by monitor technician and/or clinical patient care staff."

3. An interview conducted with the Chief Nursing Officer (CNO) on 8/5/19 at approximately 1:40 p.m. revealed the central telemetry monitoring system had been non-operational for two (2) months.

4. An interview conducted with the Director of Radiology and Respiratory Therapy on 8/6/19 at approximately 2:40 p.m. revealed the arterial blood gas (ABG) machine was working but would reach end of life in 2020. ABGs could not be done on site because they did not have the measurement cartridges needed to do the ABGs. ABG samples have been sent off site for completion starting on 7/31/19. There was not a written policy or procedure for sending the ABGs off site for processing. The Director of Radiology and Respiratory Therapy concurred with these findings during the interview.

5. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed five (5) (patients #1, 2, 3, 4 and 5) out of thirteen (13) patients on portable bedside heart monitors which were not attached to a central monitoring system.

6. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed three (3) (patients #1, 2 and 5) out of five (5) patients on the portable bedside heart monitors had the door to their room closed limiting the sound of the alarms.

7. A tour of the ICU on 8/5/19 at approximately 1:45 p.m. revealed six (6) out of six (6) bedside heart monitors were due to have planned maintenance 6/19 and had not been completed.

8. A tour of the MSU on 8/6/19 at approximately 9:20 a.m. revealed there were seven (7) portable heart monitors and three (3) of the monitors were past due for maintenance. Two (2) monitors were due for maintenance 1/19 and one (1) monitor was due for maintenance 6/19.

9. An interview was conducted with the CNO on 8/6/19 at approximately 9:20 a.m. and she concurred with these findings.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on document review, staff interviews and observation it was revealed the hospital failed to maintain supplies and equipment to ensure an acceptable level of safety and quality for five (5) (patients #1, 2, 3, 4 and 5) out of thirteen (13) patients on the medical surgical unit by not providing a central monitoring system for patients ordered telemetry or for patients in the Intensive Care Unit (ICU) as equipment used for heart monitoring on both the MSU and ICU was out of date. The facility did not have cartridges used for performing arterial blood gases (ABGs). ABG specimens were being sent to another location for completion. This failure has the potential to affect all patients requiring telemetry monitoring, intensive care monitoring and the return of emergency results for arterial blood gases.

Findings include:

1. A review of the hospital policy titled Telemetry Monitoring Utilization with an approval date of 10/26/16 revealed in part: "According to the American College of Cardiology there are several guidelines that must apply to the use of cardiac monitoring in all clinical settings. Adequate human surveillance of the monitors 24 hours per day ..."

2. A review of the hospital policy titled Clinical Alarm Management with an effective date of 10/16 revealed in part: "Alarm volume levels must be maintained at an easily audible level at all times by monitor technician and/or clinical patient care staff."

3. An interview conducted with the Chief Nursing Officer (CNO) on 8/5/19 at approximately 1:40 p.m. revealed the central telemetry monitoring system had been non-operational for two (2) months.

4. An interview conducted with the Director of Radiology and Respiratory Therapy on 8/6/19 at approximately 2:40 p.m. revealed the arterial blood gas (ABG) machine was working but would reach end of life in 2020. ABGs could not be done on site because they did not have the measurement cartridges needed to do the ABGs. ABG samples have been sent off site for completion starting on 7/31/19. There was not a written policy or procedure for sending the ABGs off site for processing. The Director of Radiology and Respiratory Therapy concurred with these findings during the interview.

5. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed five (5) (patients #1, 2, 3, 4, and 5) out of thirteen (13) patients on portable bedside heart monitors which were not attached to a central monitoring system.

6. A tour of the MSU on 8/5/19 at approximately 1:20 p.m. revealed three (3) (patients #1, 2 and 5) out of five (5) patients on the bedside heart monitors had the door to their room closed limiting the sound of the alarms.

7. A tour of the ICU on 8/5/19 at approximately 1:45 p.m. revealed six (6) of six (6) bedside heart monitors were due to have planned maintenance 6/19 and had not been completed.

8. A tour of the MSU on 8/6/19 at approximately 9:20 a.m. revealed there were seven (7) portable heart monitors and three (3) of the monitors were past due for maintenance. Two (2) monitors were due for maintenance 1/19 and one (1) monitor was due for maintenance 6/19.

9. An interview was conducted with the CNO on 8/6/19 at approximately 9:20 a.m. and she concurred with these findings.