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 21, 2017 |
| VIOLATION: Portable Space Heaters | Tag No: K0781 | |
| Based on observation and staff interview, the facility failed to prohibit portable space heating devices. Census is 10. Findings include: 1. A facility tour in the same day surgery area on 06/20/17 at 10:20 p.m. revealed a portable electric space heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit. 2. A facility tour in the infection control classroom on 06/20/17 at 12:47 p.m. revealed a portable electric heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit. 3. A facility tour in the nursing administrator's office on 06/20/17 at 2:08 p.m. revealed a portable electric heater in use. The heater utilized an element exceeding 212 degrees Fahrenheit. 4. A facility tour in the medical records department on 06/20/17 at 2:17 p.m. revealed five (5) portable electric heaters in use. The heaters utilized an element exceeding 212 degrees Fahrenheit. 5. A facility tour in the pharmacy on 06/20/17 at 2:22 p.m. revealed three (3) portable electric heaters in use. The heaters utilized an element exceeding 212 degrees Fahrenheit. 6. The Plant Manager was present during the tours on 06/20/17 and agreed the heaters were not allowed and would be removed. |
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| VIOLATION: Electrical Systems - Essential Electric Syste | Tag No: K0918 | |
| Based on document review and staff interview it was determined the facility failed to maintain the emergency generator in accordance with National Fire Protection Association 110. Census is 10. Findings include: 1. Document review on 06/19/17 at 1:00 p.m. revealed electrolyte testing for both generator batteries was incomplete. Electrolyte testing must be performed and recorded for each cell weekly. 2. Document review on 06/20/17 at 1:39 p.m. revealed no evidence of annual load bank testing for both generators. 3. The Plant Manager was present during the document reviews on 06/20/17 and agreed the generators would need to be compliant with the aforementioned code. |
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| VIOLATION: Electrical Equipment - Testing and Maintenanc | Tag No: K0921 | |
| Based on observation and staff interview it was determined the facility failed to complete electrical testing for portable patient-care related equipment. Census is 10. Findings include: 1. A facility tour of the Radiology Department on 06/21/17 at 11:00 a.m. revealed there was no evidence of electrical testing. 2. The Plant Manager was present on 06/21/17 and agreed the equipment had not been tested . |
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| VIOLATION: PHYSICAL ENVIRONMENT | Tag No: A0700 | |
| Based on observation and staff interview it was determined the facility failed to complete electrical testing in the radiology department, resulting in an unsafe condition (refer to Tag K 921). Census is 10. | ||
| VIOLATION: EMERGENCY SERVICES POLICIES | Tag No: A1104 | |
| Based on document review and staff interview it was determined the facility failed to ensure the Emergency Department (ED) staff followed facility policy and accurately completed the ED Central Log Book for three (3) of three (3) months reviewed (April 2017, May 2017 and June 2017). This deficient practice has the potential to negatively affect the prompt care and disposition of all patients. Findings include: 1. Review of the ED Central Log Book from 4/1/17 through 6/19/17 revealed incomplete documentation as follows: April 2017 had four (4) days of incomplete documentation; May 2017 had eight (8) days of incomplete documentation; and, June 2017 had eight (8) days of incomplete documentation. 2. Review of the facility policy titled "Registering of Patients in the ER Log", last reviewed 4/10, revealed it states, in part: "...any patient presenting for emergency care, or a woman in labor, as designated by EMTALA are to be registered on a Central Log, herein identified as the emergency room log. The purpose of this log is to track the care provided to each individual presenting for care and treatment...The Admissions Department will forward a copy of the ER patient's face sheet to the ER. The ER clerical staff is to record this data in the log on Optimun. Under the treatment section of the log book the clerk will note all treatment given while in the ER." 3. Review of the emergency room (ER) staff meeting minutes for February 2017 revealed it states, in part: "All patients triaged from front will be logged by the Mid-Level. All patients triaged from ambulance entrance will be logged by the RN who is triaging the patient. The nurse/mid-level discharging/admitting/transferring etc, is responsible for filling in the disposition, disposition diagnosis, date and time on the log book. It is to be filled out immediately on disposition. If you fail to do your job disciplinary actions will be enforced. Do not write the complaint in the log book. Write the disposition diagnosis. The Unit Clerks will be the second eye and recheck the log book to make sure all patients were logged and the disposition is completed. No one is to leave from their scheduled shift without making sure the log is up to date..." 4. The above findings were reviewed on 6/21/17 at 11:14 a.m. with the ER Nurse Manager. She confirmed the findings. |
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| VIOLATION: Fire Drills | Tag No: K0712 | |
| Based on document review and staff interview it was determined the facility failed to perform fire drills at unexpected times and under varying conditions. Census is 10. Findings include: 1. Document review on 06/19/17 at 1:19 p.m. revealed day shift fire drills were performed at 7:03 a.m. on the second quarter, 7:05 a.m. on the third quarter and 7:02 a.m. on the fourth quarter. Evening shift fire drills were performed at 9:05 p.m. on the second quarter and 9:15 p.m. on the third quarter. Midnight shift fire drills were performed at 11:23 p.m. on the third quarter and 11:06 p.m. on the fourth quarter. 2. The Plant Manager was present during the review on 06/20/17 and agreed the fire drills would need to show random times. |
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