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.

PRINCETON COMMUNITY HOSPITAL 122 12TH STREET PRINCETON, WV 24740 Aug. 12, 2020
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
Based on document review, medical record review and interviews it was revealed the hospital failed to document the request of the patient's representative to change the Medical Power of Attorney's (MPOA) other directive section from Do Not Resuscitate (DNR) to Full Code and failed to document the reason for the denial of the request in one (1) of thirty (30) patients (patient #1). This failure has the potential to adversely affect communication between caregivers for all patients.

Findings include:

1. A document review of the hospital policy entitled 'Plan for Provision of Patient Care, Treatment and Services,' last revision date 3/20, revealed in part: "Case Management Staff: Documentation of case management activity to promote interdisciplinary care provision ..."

2. A review of the medical record for patient #2 revealed there was no documentation that the patient representative made a request to change the DNR on the MPOA to Full Code. There was also no documentation explaining why the request could not be honored.

3. An interview conducted with the case manager on 8/11/20 at approximately 1:00 p.m. revealed the patient representative told her she wanted the MPOA document changed from DNR to Full Code. The case manager told the patient representative they could not change the MPOA document. The case manager stated she thought she documented this conversation but agreed it was not in the patient record.

4. An interview was conducted with the Compliance Officer/Risk Management on 8/12/20 at approximately 7:30 a.m. and she concurred with the above findings.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, document review and interviews it was revealed the Infection Preventionist failed to ensure all visitors are screened appropriately to prevent and control the transmission of the COVID-19 Coronavirus. This failure was identified in four (4) out of five (5) visitor entrance screenings. This failure has the potential to place all patients, staff and visitors at risk for infection.

Findings include:

1. An observation conducted on 08/10/20 at approximately 1:00 p.m. at the hospital main entrance revealed screener/greeter #1 did not ask questions to screen visitors (visitor #1 and #2) for signs and symptoms, having traveled to areas with high risk of COVID-19 infections or having contact with any potentially infected COVID-19 individuals.

2. An observation conducted on 08/11/20 at approximately 3:30 p.m. at the hospital main entrance revealed screener/greeter #2 and #3 did not ask questions to screen visitor #1 for signs and symptoms, having traveled to areas with high risk of COVID-19 infections or having contact with any potentially infected COVID-19 individuals.

3. An interview was conducted on 08/12/20 at approximately 9:15 a.m. with visitor #3. When asked if she had been asked screening questions when she entered the hospital main entrance she stated, "No, they didn't ask me any questions, they just took my temperature."

4. A review of the "Screener Scripting" protocol dated 06/26/20 states in part: "All individuals should be masked when entering the building ... If > 100.4, visitor (even if essential) will not be allowed to enter. ... Patient here for outpatient testing. Check temp give mask if does not have one."

5. A review of the "Guidelines for Reimplementation of No Visitors" protocol dated 6/26/20 states in part: "Any individual that is deemed an essential caregiver must be an adult who is well ... must be compliant with masking ... They will be screened prior to being allowed in the building. Screening protocols and strict universal masking policies remain in place."

6. A review of the "Hospital Entrance Screener Greeter" job description published 07/02/20 states in part: "The Hospital Entrance Screener/Greeter is responsible for taking temperatures of patients and visitors; asking standard health screening questions ...."

7. An interview with the Infection Preventionist was conducted on 08/12/20 at approximately 2:12 p.m. When asked if the Screener Greeter should be asking questions when screening visitors at the entrances she stated in part: "They are to ask if they have traveled, do they have any symptoms, are short of breath, have a cough and fatigue and if they have traveled outside of the United States or to hotspots and if exposed to a COVID patient."
VIOLATION: IC PROFESSIONAL TRAINING Tag No: A0775
Based on observation, document review and interviews it was revealed the Director of Quality and Case Management failed to ensure assigned hospital staff screening visitors at entrances received training and education to appropriately screen visitors to prevent and control the transmission of the COVID-19 Coronavirus. This failure was identified in four (4) out of five (5) visitor entrance screenings. This failure has the potential to place all patients, staff and visitors at risk for infection.

Findings include:

1. An observation conducted on 08/10/20 at approximately 1:00 p.m. at the hospital main entrance revealed screener/greeter #1 did not ask questions to screen visitors (visitor #1 and #2) for signs and symptoms, having traveled to areas with high risk of COVID-19 infections or having contact with any potentially infected COVID-19 individuals.

2. An observation conducted on 08/11/20 at approximately 3:30 p.m. at the hospital main entrance revealed screener/greeter #2 and #3 did not ask questions to screen visitors #1 for signs and symptoms, having traveled to areas with high risk of COVID-19 infections or having contact with any potentially infected COVID-19 individuals.

3. An interview was conducted on 08/12/20 at approximately 9:15 a.m. with visitor #3. When asked if she had been asked screening questions when she entered the hospital main entrance she stated, "No, they didn't ask me any questions, they just took my temperature."

4. A review of the "Screener Scripting" protocol dated 06/26/20 states in part: "All individuals should be masked when entering the building ... If > 100.4, visitor (even if essential) will not be allowed to enter. ... Patient here for outpatient testing. Check temp give mask if does not have one."

5. A review of the "Guidelines for Reimplementation of No Visitors" protocol dated 6/26/20 states in part: "Any individual that is deemed an essential caregiver must be an adult who is well ... must be compliant with masking ... They will be screened prior to being allowed in the building. Screening protocols and strict universal masking policies remain in place."

6. A review of the "Hospital Entrance Screener Greeter" job description published 07/02/20 states in part: "The Hospital Entrance Screener/Greeter is responsible for taking temperatures of patients and visitors; asking standard health screening questions ...."

7. An interview with the Infection Preventionist was conducted on 08/12/20 at approximately 2:12 p.m. When asked if the Screener Greeter should be asking questions when screening visitors at the entrances she stated in part: "They are to ask if they have traveled, do they have any symptoms, are short of breath, have a cough and fatigue and if they have traveled outside of the United States or to hotspots and if exposed to a COVID patient."

8. An interview with the Director of Quality and Case Management was conducted on 08/12/20 at approximately 3:15 p.m. When asked if the Screener Greeters received education and training to screen visitors she stated in part: "We have no training documentation for the Screeners Greeters. ... We were meeting with them on the Scripting for temperatures and mask."