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.

SUMMERSVILLE REGIONAL MEDICAL CENTER 400 FAIRVIEW HEIGHTS ROAD SUMMERSVILLE, WV 26651 Dec. 12, 2012
VIOLATION: MEDICAL STAFF - ACCOUNTABILITY Tag No: A0049
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documents, medical records and staff interview it was determined the facility failed to ensure the medical staff was accountable to the governing body in ten (10) of ten (10) medical records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) for the time and date of physician signatures on physician orders. This has the potential to negatively affect all patients by leaving them with incomplete medical records.

Findings include:

1. The Bylaws, Rules and Regulations of the medical staff, last reviewed 4/8/11 states in part: "L. Autointoxication of Entries. All clinical entries in the patient medical record must be accurately dated, timed and authenticated." General Conduct of Care in the Rules and Regulations also states in part: "2. The responsible practitioner shall authenticate verbal orders at the next visit or in no event later than twenty four (24) hours.

2. Patient #1 was admitted on [DATE]. Physician verbal orders written by nursing at 1600 on 10/23/12, were authenticated by the physician without a date or time.

3. Patient #2 was admitted on [DATE]. Admission orders signed by the physician do not contain a date or time. Verbal orders written on 10/31/12 at 2030, 10/31/12 at 2230, 11/1/12 at 0130 and 11/2/12 at 2130 contain a physician signature without a date and time.

4. Patient #3 was admitted on [DATE]. Admission orders signed by the physician do not contain a date or time. Post Partum orders signed by the physician do not contain a date or time. Labor check at term orders do not contain a date or time. Verbal orders written on 9/18/12 contain the physician signature without a date or time.

5. Patient #4 was admitted on [DATE]. Admission orders signed by the physician do not contain a date of time. Verbal orders written on 10/8/12 at 0005 contain a signature without a date or time.

6. Patient #5 was admitted on [DATE]. Three (3) verbal orders written on 10/24/12 (no time documented), have been signed by the physician without a date or time. Routine Post-Partum orders have been signed by the physician and do not contain a date or time.

7. Patient #6 was admitted on [DATE]. Routine Labor Admit Orders are signed by the physician and do not contain a date or time. Oxytocin Induction/Augmentation orders do not contain a date or time. Routine Post-Partum orders do not contain a date or time with the physician signature. Verbal orders written on 10/30/12 at 0615 and on 10/30/12 at 1350 do not contain a time or date with the physician signature.

8. Patient #7 was admitted on [DATE]. Two (2) verbal orders written on 6/15/12 at 2135 contain a physician signature without a date or time.

9. Patient #8 was admitted on [DATE]. Verbal orders written on 10/22/12 at 1900 contain a physician signature without a date or time.

10. Patient #9 was admitted on [DATE]. Anesthesia orders for Post Anesthesia Care written as verbal order on 4/12/12 contained a physician signature without a date or time. Verbal orders written on 4/13/12 at 0000 contain a physician signature without a date or time.

11. Patient #10 was admitted on [DATE]. Verbal orders written by nursing (no date or time), noted by nursing on 10/30/12 at 2000, were signed by the physician without a date or time.

12. During an interview with the OB unit Clinical Nurse Manager on 12/11/12 at approximately 1400, she agreed with the findings in these medical records.
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of documents and staff interview, it was determined the facility failed to ensure the policy is being followed in relation to grievances and the provision of a response. This has the potential to negatively affect all persons filing complaints with the facility in that their concerns are not being met in a timely manner.

Findings include:

1. During an interview with the Risk Manage (RM) on 12/11/12 at approximately 1100, review of the policy for grievances was reviewed. The RM admitted all complainants are not getting a letter of response. He revealed the current system needs changed and he is looking at ways to incorporate the clinical nurse managers in the process. He stated he felt this would assist with "ownership" of the specific units the complaints are directed at and would also be an asset to him with the specific nurse managers investigating and then responding to him with the findings. He also revealed he was aware response times were not always met, nor were letters being sent to all complainants.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure all patients received care in a safe setting by not ensuring hospital policies were being followed in nine (9) of ten (10) medical records reviewed (#1, 2, 3, 5, 6, 7, 8, 9, 10). This has the potential to negatively affect the care of all patients, by the potential for harm due to policies not being followed.

Findings include:

1. Hospital policy titled Post-Partum Care states in part: " Procedure for immediate post partum care: (2). Obtain vital signs every fifteen (15) minutes. (3). Document all observations, treatments, teaching, vital signs, and other nursing care given. Procedure for Routine Post Partum care after initial hour: (1) Continue to assess the fundus and amount of bleeding as frequently as indicated; at least every one hour for the first four hours, every four hours for the remainder of the first post partum day, and then once a shift until discharge. (3) obtain vital signs every four (4) hours."

2. Patient #1 delivered her fetus at 0630 on 10/24/12. The medical record does not contain documentation relative to care of the post partum patient.

3. Patient #2 delivered at 1416 on 11/1/12. The medical record does not contain documentation relative to care of the post partum patient.

4. Patient #3 delivered at 0511 on 9/19/12. The medical record does not contain documentation relative to care of the post partum patient.

5. Patient #5 delivered at 0450 on 10/25/12. The medical record does not contain documentation relative to care of the post partum patient.

6. Patient #6 delivered at 2157 on 10/30/12. The medical record does not contain documentation relative to care of the post partum patient.

7. Patient #7 delivered at 0150 on 6/16/12. The medical record does not contain documentation relative to care of the post partum patient.

8. Patient #8 delivered at 1833 on 10/22/12. The medical record does not contain documentation relative to care of the post partum patient.

9. Patient #9 delivered at 2030 on 4/12/12. The medical record does not contain documentation relative to care of the post partum patient.

10. Patient #10 delivered at 1843 on 10/30/12. The medical record does not contain documentation relative to care of the post partum patient.

11. During an interview with the Clinical Nurse Manager on 12/11/12 at approximately 1400 these medical records were reviewed and she agreed with these findings.

B. Based on review of documents, medical records and staff interview it was determined the facility failed to ensure staff were following hospital policy as it pertained to discharge of the maternity patient in ten (10) of ten (10) medical records reviewed (1, 2, 3, 4, 5, 6, 7, 8, 9, 10). This has the potential to negatively affect patient care by the potential for injury to occur with patient's being discharged unattended.

Findings include:

1. Hospital policy titled Discharge of Maternity Patients states in part: "1. Maternity patients are taken by wheelchair and parents are assisted with the infant and belongings to their vehicle at the front entrance of the hospital. 2. Complete the patient's chart, including date and time of discharge, mode of transportation, who accompanied the patient, patient's condition, patient and family teaching performed and the response and any observations."

2. Patient #1 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

3. Patient #2 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

4. Patient #3 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

5. Patient #4 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

6. Patient #5 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

7. Patient #6 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

8. Patient #7 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

9. Patient #8 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

10. Patient #9 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

11. Patient #10 was discharged on [DATE]. Documentation in the patient medical record did not follow hospital policy relative to discharge of the maternity patient.

12. During an interview with the Clinical Nurse Manager on 12/11/12 at approximately 1400 these medical records were reviewed and she agreed with these findings
VIOLATION: MEDICAL STAFF ACCOUNTABILITY Tag No: A0347
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documents, medical records and staff interview it was determined the facility failed to ensure the medical staff was accountable to the governing body in ten (10) of ten (10) medical records reviewed (#1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) for the time and date of physician signatures on physician orders. This has the potential to negatively affect all patients by leaving them with incomplete medical records.

Findings include:

1. The Bylaws, Rules and Regulations of the medical staff, last reviewed 4/8/11 states in part: "L. Autointoxication of Entries. All clinical entries in the patient medical record must be accurately dated, timed and authenticated." General Conduct of Care in the Rules and Regulations also states in part: "2. The responsible practitioner shall authenticate verbal orders at the next visit or in no event later than twenty four (24) hours".

2. Patient #1 was admitted on [DATE]. Physician verbal orders written by nursing at 1600 on 10/23/12, were authenticated by the physician without a date or time.

3. Patient #2 was admitted on [DATE]. Admission orders signed by the physician do not contain a date or time. Verbal orders written on 10/31/12 at 2030, 10/31/12 at 2230, 11/1/12 at 0130 and 11/2/12 at 2130 contain a physician signature without a date and time.

4. Patient #3 was admitted on [DATE]. Admission orders signed by the physician do not contain a date or time. Post Partum orders signed by the physician do not contain a date or time. Labor check at term orders do not contain a date or time. Verbal orders written on 9/18/12 contain the physician signature without a date or time.

5. Patient #4 was admitted on [DATE]. Admission orders signed by the physician do not contain a date of time. Verbal orders written on 10/8/12 at 0005 contain a signature without a date or time.

6. Patient #5 was admitted on [DATE]. Three (3) verbal orders written on 10/24/12 (no time documented), have been signed by the physician without a date or time. Routine Post-Partum orders have been signed by the physician and do not contain a date or time.

7. Patient #6 was admitted on [DATE]. Routine Labor Admit Orders are signed by the physician and do not contain a date or time. Oxytocin Induction/Augmentation orders do not contain a date or time. Routine Post-Partum orders do not contain a date or time with the physician signature. Verbal orders written on 10/30/12 at 0615 and on 10/30/12 at 1350 do not contain a time or date with the physician signature.

8. Patient #7 was admitted on [DATE]. Two (2) verbal orders written on 6/15/12 at 2135 contain a physician signature without a date or time.

9. Patient #8 was admitted on [DATE]. Verbal orders written on 10/22/12 at 1900 contain a physician signature without a date or time.

10. Patient #9 was admitted on [DATE]. Anesthesia orders for Post Anesthesia Care written as verbal order on 4/12/12 contained a physician signature without a date or time. Verbal orders written on 4/13/12 at 0000 contain a physician signature without a date or time.

11. Patient #10 was admitted on [DATE]. Verbal orders written by nursing (no date or time), noted by nursing on 10/30/12 at 2000, were signed by the physician without a date or time.

12. During an interview with the OB unit Clinical Nurse Manager on 12/11/12 at approximately 1400, she agreed with the findings in these medical records.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
A. Based on review of documents, medical records and staff interview, it was determined the facility failed to ensure nursing documented and evaluated the nursing care of the patient in three (3) of five (5) medical records reviewed for the disposition of a fetus (#1, 8, 9). This has the potential to negatively affect all patients by leaving their wishes unknown and their medical records incomplete.

Findings include:

1. Hospital policy titled Fetal Demise and Live Birth, Then Death states in part: "Disposition of the stillborn fetus: (A) Any fetal death, up to and including full term delivery, may be disposed of by hospital authorities with parental consent. The permission of the parent(s) must be secured, whatever the disposition. (B) Parent(s) may choose to take the fetus home for burial, in which case the short blue Burial-Transit Permit must accompany the fetus."

2.. Patient #1 delivered a still born fetus. There is no documentation in the medical record indicating nursing had discussed the disposition of the fetus with the parent nor were the proper forms filled out.

3. Patient #8 delivered a stillborn fetus. There is no documentation in the medical record indicating nursing had discussed the disposition of the fetus with the parent nor were the proper forms filled out.

4. Patient #9 delivered a stillborn fetus. There is no documentation in the medical record indicating nursing had discussed the disposition of the fetus with the parent nor were the proper forms filled out.

5. During an interview with the Clinical Nurse Manager of the Obstetrical Unit on 12/11/12 at approximately 1400, these records were reviewed and she agreed with these findings.

B. Based on review of documents, medical records and staff interview it was determined the facility failed to ensure nursing individualized the care plan in five (5) of (5) records for the development of the Care plan (#1, 7, 8, 9, 10). This has the potential to negatively affect all patients by leaving their wishes unknown and their medical records incomplete.

Findings include:

1. Hospital policy titled Care Planning states in part: "The Plan of Care shall be individualized, based on the diagnosis and patient assessment."

2. Patient #1 delivered a stillborn fetus. There was no documentation in the medical record to indicate the care plan, developed by nursing identified fetal loss or bereavement as a potential problem.

3. Patient #7 delivered a stillborn fetus. There was no documentation in the medical record to indicate the care plan, developed by nursing identified fetal loss or bereavement as a potential problem.

4. Patient #8 delivered a stillborn fetus. There was no documentation in the medical record to indicate the care plan, developed by nursing identified fetal loss or bereavement as a potential problem.

5. Patient #9 delivered a stillborn fetus. There was no documentation in the medical record to indicate the care plan, developed by nursing identified fetal loss or bereavement as a potential problem.

6. Patient #10 delivered a stillborn fetus. There was no documentation in the medical record to indicate the care plan, developed by nursing identified fetal loss or bereavement as a potential problem.

7. During an interview with the Clinical Nurse Manager of the Obstetrical Unit on 12/11/12 at approximately 1400, these records were reviewed and she agreed with these findings.