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 | June 1, 2021 |
| VIOLATION: PATIENT RIGHTS | Tag No: A0115 | |
| Based on document review, policy review and staff interview it was found that the hospital failed to ensure patient #1 received care in a safe setting (see tag A 144). This failure likely contributed to the death of patient #1. A. An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (Failure to Follow Policy and Procedures) was called on 6/1/21 at 9:25 a.m. because the hospital failed to ensure Nursing Services followed the hospital's policies and procedures for monitoring a patient on telemetry on the Medical/Surgical floor. B. Harm or Potential Harm: An adverse outcome occurred due to Nursing Services not actively monitoring the telemetry monitors. This potentially contributed to patient #1 being found deceased in his bed approximately forty-two (42) minutes after he had a telemetry strip showing he was having a cardiac emergency. C. Immediacy: The hospital must ensure someone is monitoring the telemetry monitors at all times. D. A remedial plan of correction was received and sent to the State agency Program Director. It was accepted by the surveyor and the facility abated the IJ on 6/1/21 at 12:30 p.m. by re-educating all Intensive Care Unit (ICU) staff that the telemetry monitors located in ICU will be monitored twenty-four (24) hours a day seven (7) days a week by a telemetry trained nurse. |
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| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| Based on document review, policy review and staff interview it was determined the hospital failed to ensure patient #1 was actively being monitored while on telemetry. This failure potentially contributed to his demise. Findings include: 1. A review of the medical record of patient #1 revealed an eighty-four (84) year old male who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 1/5/21 with complaints of shortness of breath. He was diagnosed with acute on chronic Hypercarbic/hypoxic respiratory failure, pneumonia, dyspnea, and wheezing. The patient refused to be intubated and was placed on Bi-Pap for comfort. A Do Not Resuscitate (DNR) order was given verbally by the patient's Medical Power of Attorney (MPOA). The patient was kept in the ED until a bed became available on the Medical/Surgical floor. He arrived on the Medical/Surgical floor at 3:00 p.m. on 1/6/21. He had a blood transfusion that began at 4:20 p.m. and was completed at 8:40 p.m. The record indicated at 6:45 p.m. the patient was eating a sandwich and drinking milk while using oxygen at 5 L nasal canula. At 6:55 p.m. he was placed back on Bi-Pap. At 9:04 p.m. the telemetry strip shows the patient was either bradycardic or in pulseless electrical activity (PEA). At 9:43 p.m. the telemetry strip shows the patient was in asystole. At 9:45 the record indicates that Registered Nurse (RN) #1 entered the patient's room and found him unresponsive and yelled for the physician to come to bedside. The physician responded with RN #1 to the patient's room and pronounced the patient deceased . Center for Organ Recovery and Education (CORE) was notified, and the physician did complete a death certificate. 2. A review of the hospital document entitled, 'Progress Notes' dated 1/6/21 at 9:45 p.m. states, "In to give patient his medications. Patient noted to be not breathing and no pulse. Physician called to bedside. Checked with ICU to verify telemetry. Patient noted to have asystole at 9:42 p.m. according to telemetry monitor. Physician pronounced death at 9:50 p.m." The note was signed by RN #1. 3. A review of the hospital document entitled, 'Physician Progress Notes' dated 1/6/21 at 9:57 p.m. states, "The nurse walked in the patient's room approximately 15 minutes ago found the patient with no vital signs. Telemetry showed asystole. No cardio-respiratory activity could be heard he had no blood pressure pronounced dead at 9:50 p.m." The note was signed by the physician. 4. A review of the hospital document entitled, 'Telemetry,' last revised 1/14, states in part: "If there is a malfunction in the telemetry unit while it is operational, it is the responsibility of the ICU nurse to bring the malfunction to the Med/Surg nurse's attention so the Med/Surg nurse may correct the problem. If an arrhythmia is observed, it is the ICU nurse's responsibility to run a strip and give strip to Med/Surg RN or Charge Nurse. The Med/Surg RN will then notify the physician if he/she thinks this is an appropriate action for the observed ectopy." 5. An interview was conducted with the Chief Nursing Officer (CNO) on 5/31/21 at approximately 11:00 a.m. She explained that normally a patient on Bi-Pap was not placed on the Medical/Surgical floor. However, this patient was a DNR with comfort measures, so he was placed on the floor with telemetry. She stated, "The telemetry monitor is kept in ICU. If the monitor is alarming it is the ICU nurse's responsibility to notify the floor nurses of the alarm. Staffing was not ideal that night for the Med/Surg floor. There was one (1) RN and one (1) Licensed Practical Nurse (LPN) to cover the floor. We had twenty (20) plus staff out with COVID. The Chief Executive Officer (CEO) mandated overtime. The CEO and I were staffing units to make sure the units were covered. The patient was in a room by the nurse's desk. He was still a person under investigation (PUI), so he was behind two (2) doors. The nurses were a few doors down taking care of other patients. The nurses probably didn't hear the alarms going off on the Bi-Pap. There was something wrong with the time on the telemetry strips. For some reason they were an hour off. There is no documentation to show if the ICU nurses called to let them know the alarm was going off on the monitor." She explained that RN #1 and RN #2 were travel nurses and no longer working at the hospital. 6. An interview was conducted with LPN #1 on 6/1/21 at approximately 8:55 a.m. She stated, "I remember around 8:00 p.m. the patient had pulled his Bi-Pap off and was panicking. We went in to put the Bi-Pap back on him and try to calm him down. I was at the nurse's desk when RN #1 came out into the hall and told me to get the physician that there was something wrong with the patient. The doctor asked me to go over into ICU and check to see if patient had a rhythm and he didn't. He was in asystole and then he pronounced him." When asked if she had made any documentation in the medical record she stated, "No, he wasn't my patient, so I didn't chart anything. I thought RN # 1 had charted on him." She stated no one had called from ICU that she was aware of to tell them that the monitor was alarming. 7. An interview was conducted with LPN #2 on 5/31/21 at approximately 12:10 p.m. She stated, "I was working in ICU that night. We had four (4) patients on Bi-Pap. Alarms were going off everywhere. We were having to prone our patients every thirty (30) minutes. I don't remember hearing anyone mention the alarms going off for Med/Surg, but alarms were going off everywhere, so I really don't know. I was too busy taking care of my patients in the ICU." 8. An interview was conducted with the CNO on 6/1/21 at approximately 8:15 a.m. She concurred there was no documentation to prove that RN #2 notified RN #1 that the telemetry monitor was alarming on patient #1. She stated that the strip times were an hour off, and the Nurse Manager of ICU began doing a daily Q/A (Quality Assurance) to make sure the monitors have accurate times on them. |
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| VIOLATION: NURSING SERVICES | Tag No: A0385 | |
| Based on document review, policy review and staff interview it was determined the hospital failed to ensure nursing services followed nursing policy and procedure when monitoring a telemetry patient in one (1) of ten (10) medical records reviewed (patient #1) ( See tag A 398). A. An IJ to Patient Rights (Care in a Safe Setting) and Nursing Services (Failure to Follow Policy and Procedures) was called on 6/1/21 at 9:25 a.m. because the hospital failed to ensure Nursing Services followed the hospital's policies and procedures for monitoring a patient on telemetry on the Medical/Surgical floor. B. Harm or Potential Harm: An adverse outcome occurred due to Nursing Services not actively monitoring the telemetry monitors. This potentially contributed to patient #1 being found deceased in his bed approximately forty-two (42) minutes after he had a telemetry strip showing he was having a cardiac emergency. C. Immediacy: The hospital must ensure someone is monitoring the telemetry monitors at all times. D. A remedial plan of correction was received and sent to the State agency Program Director. It was accepted by the surveyor and the facility abated the IJ on 6/1/21 at 12:30 p.m. by re-educating all Intensive Care Unit (ICU) staff that the telemetry monitors located in ICU will be monitored twenty-four (24) hours a day seven (7) days a week by a telemetry trained nurse. |
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| VIOLATION: SUPERVISION OF CONTRACT STAFF | Tag No: A0398 | |
| Based on document review, policy review and staff interview it was determined the hospital failed to ensure nursing staff followed telemetry policy and procedure in one (1) of ten (10) records reviewed (patient #1). This failure potentially contributed to the death of patient #1. Findings include: 1. A review of the medical record of patient #1 revealed an eighty-four (84) year old male who presented to the Emergency Department (ED) via Emergency Medical Services (EMS) on 1/5/21 with complaints of shortness of breath. He was diagnosed with acute on chronic Hypercarbic/hypoxic respiratory failure, pneumonia, dyspnea and wheezing. The patient refused to be intubated and was placed on Bi-Pap for comfort. A Do Not Resuscitate (DNR) order was given verbally by the patient's Medical Power of Attorney (MPOA). The patient was kept in the ED until a bed became available on the Medical/Surgical floor. He arrived on the Medical/Surgical floor at 3:00 p.m. on 1/6/21. He had a blood transfusion that began at 4:20 p.m. and was completed at 8:40 p.m. The record indicated at 6:45 p.m. the patient was eating a sandwich and drinking milk while using oxygen at 5 L nasal canula. At 6:55 p.m. he was placed back on Bi-Pap. At 9:04 p.m. the telemetry strip shows the patient was either bradycardic or in pulseless electrical activity (PEA). At 9:43 p.m. the telemetry strip shows the patient was in asystole. At 9:45 the record indicates that Registered Nurse (RN) #1 entered the patient's room and found him unresponsive and yelled for the physician to come to bedside. The physician responded with RN #1 to the patient's room and pronounced the patient deceased . Center for Organ Recovery and Education (CORE) was notified and the physician did complete a death certificate. 2. A review of the hospital document entitled, 'Progress Notes' dated 1/6/21 at 9:45 p.m. states, "In to give patient his medications. Patient noted to be not breathing and no pulse. Physician called to bedside. Checked with ICU to verify telemetry. Patient noted to have asystole at 9:42 p.m. according to telemetry monitor. Physician pronounced death at 9:50 p.m." The note was signed by RN #1. 3. A review of the hospital document entitled, 'Physician Progress Notes' dated 1/6/21 at 9:57 p.m. states, "The nurse walked in the patient's room approximately 15 minutes ago found the patient with no vital signs. Telemetry showed asystole. No cardio-respiratory activity could be heard he had no blood pressure pronounced dead at 9:50 p.m." The note was signed by the physician. 4. A review of the hospital document entitled, 'Telemetry,' last revised 1/14, states in part: "If there is a malfunction in the telemetry unit while it is operational, it is the responsibility of the ICU nurse to bring the malfunction to the Med/Surg nurse's attention so the Med/Surg nurse may correct the problem. If an arrhythmia is observed, it is the ICU nurse's responsibility to run a strip and give strip to Med/Surg RN or Charge Nurse. The Med/Surg RN will then notify the physician if he/she thinks this is an appropriate action for the observed ectopy." 5. An interview was conducted with the Chief Nursing Officer (CNO) on 5/31/21 at approximately 11:00 a.m. She explained that normally a patient on Bi-Pap was not placed on the Medical/Surgical floor. However this patient was a DNR with comfort measures so he was placed on the floor with telemetry. She stated, "The telemetry monitor is kept in ICU. If the monitor is alarming it is the ICU nurse's responsibility to notify the floor nurses of the alarm. Staffing was not ideal that night for the Med/Surg floor. There was one (1) RN and one (1) Licensed Practical Nurse (LPN) to cover the floor. We had twenty (20) plus staff out with COVID. The Chief Executive Officer (CEO) mandated overtime. The CEO and myself were staffing units to make sure the units were covered. The patient was in a room by the nurse's desk. He was still a person under investigation (PUI) so he was behind two (2) doors. The nurses were a few doors down taking care of other patients. The nurses probably didn't hear the alarms going off on the Bi-Pap. There was something wrong with the time on the telemetry strips. For some reason they were an hour off. There is no documentation to show if the ICU nurses called to let them know the alarm was going off on the monitor." She explained that RN #1 and RN #2 were travel nurses and no longer working at the hospital. 6. An interview was conducted with LPN #1 on 6/1/21 at approximately 8:55 a.m. She stated, "I remember around 8:00 p.m. the patient had pulled his Bi-Pap off and was panicking. We went in to put the Bi-Pap back on him and try to calm him down. I was at the nurse's desk when RN #1 came out into the hall and told me to get the physician that there was something wrong with the patient. The doctor asked me to go over into ICU and check to see if patient had a rhythm and he didn't. He was in asystole and then he pronounced him." When asked if she had made any documentation in the medical record she stated, "No, he wasn't my patient so I didn't chart anything. I thought RN # 1 had charted on him." She stated no one had called from ICU that she was aware of to tell them that the monitor was alarming. 7. An interview was conducted with LPN #2 on 5/31/21 at approximately 12:10 p.m. She stated, "I was working in ICU that night. We had four (4) patients on Bi-Pap. Alarms were going off everywhere. We were having to prone our patients every thirty (30) minutes. I don't remember hearing anyone mention the alarms going off for Med/Surg but alarms were going off everywhere so I really don't know. I was too busy taking care of my patients in the ICU." 8. An interview was conducted with the CNO on 6/1/21 at approximately 8:15 a.m. She concurred there was no documentation to prove that RN #2 notified RN #1 that the telemetry monitor was alarming on patient #1. She stated that the strip times were an hour off and the Nurse Manager of ICU began doing a daily Q/A (Quality Assurance) to make sure the monitors have accurate times on them. |
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