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.

FAIRMONT REGIONAL MEDICAL CENTER 1325 LOCUST AVENUE FAIRMONT, WV 26554 Sept. 6, 2018
VIOLATION: PATIENT RIGHTS: NOTICE OF RIGHTS Tag No: A0117
Based on document review and staff interviews, it revealed the facility failed to ensure an informed consent was obtained for each patient prior to furnishing patient care. This failsure was identified in two (2) of ten (10) medical records reviewed (patient #5 and #8). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #5 revealed patient #5 was brought to the Emergency Department (ED) on 8/19/18 at 10:22 p.m. with a diagnosis of stabbing to the left chest. Patient #5 was triaged at 10:25 p.m. and the nurse documented patient #5 was oriented and obeyed commands. Further review revealed no signature for consent to treat was obtained. Documentation on the consent forms stated unable to sign due to injuries.

2. A review of the medical record for patient #8 revealed patient #8 was brought to the ED on 6/10/18 at 7:05 p.m. due to an ATV accident. Patient #8 arrived as a walk in-patient. Documentation revealed patient #8 is a minor and the parents of patient #8 were present in the ED. A review of the consent forms for patient #8 revealed no signature of consent to treat was obtained.

3. During an interview with the Director of the ED on 9/5/18 at 11:07 a.m. the director was asked if a signature for consent should have been obtained for patient #5 and 8 and she said yes. She concurred no consent for treatment was obtained for patient #5 and #8.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A. Based on document review and staff interviews, it was revealed the ED medical staff failed to provide care in a safe setting. This failure was identified in four (4) of ten (10) medical records reviewed for patients #6, 7, 9 and 10. This failure has the potential to adversely affect all patient care.

Findings include:

1. A review of the medical record for patient #6 revealed a priority two (2) trauma was called by the triage nurse at 10:19 p.m. on 6/20/18. Patient #6 was seen by the provider at 10:24 p.m. The ED physician documentation was dictated/created by the Physician Assistant (PA) at 10:35 p.m. on 6/20/18 and electronically signed by the PA at 2:15 a.m. on 6/21/18. The attending physician electronically signed this documentation at 6:50 a.m. on 6/21/18.

2. A review of the medical record for patient #7 revealed a priority one (1) trauma was called by the triage nurse at 1:31 a.m. on 6/14/18. Patient #7 was seen by the provider at 1:42 a.m. The ED physician documentation was created by the PA at 2:13 a.m. on 6/14/18. The PA stated in his documentation in the initial comments: "Patient was immediately sent to the scanner and West Virginia University was contacted for a priority 1 transfer, emergency department to emergency department." Further review revealed the PA stated in his documentation in the medical decision making section: "Emergency 911 transfer has been ordered to West Virginia University spoke with the accepting physician at West Virginia University. His name is on chart. Patient stable for transfer." This ED physician documentation created by the PA was electronically signed by the PA at 2:23 a.m. on 6/14/18. An addendum to this ED physician documentation was created by the PA at 2:32 a.m. on 6/14/18 and electronically signed by the PA at 2:32 a.m. and electronically signed by the attending physician at 6:45 a.m. Another ED physician documentation was created by the attending physician at 2:14 a.m. on 6/14/18 and electronically signed by the attending physician at 2:20 a.m on 6/14/18. No documentation of contact to West Virginia University ED was noted in the attending physician documentation. The PA documented the transfer of patient #7 to another facility.

3. A review of the medical record for patient #9 revealed a priority one (1) trauma was called by the triage nurse at 10:56 p.m. on 6/3/18. Patient #9 was seen by the provider at 11:04 p.m. The ED physician documentation was created by the PA at 12:02 a.m. on 6/4/18. The PA stated in his documentation in the initial comments: "A priority one (1) trauma was called before a provider could assess the patient. This does not meet the criteria for a priority one (1) trauma." This ED physician documentation was electronically signed by the PA at 12:09 a.m. on 6/4/18 and electronically signed by the attending physician at 6:31 a.m. on 6/4/18.

4. A review of the medical record for patient #10 revealed a priority two (2) trauma was called by the triage nurse at 1:46 a.m. on 5/21/18. Patient #10 was seen by the provider at 1:49 a.m. on 5/21/18. The ED physician documentation was created by the PA at 1:51 a.m. on 5/21/18. This ED physician documentation was electronically signed by the PA at 3:23 a.m. on 5/21/18. An addendum to this documentation was created by the PA at 3:48 a.m. on 5/21/18. This Addendum was electronically signed by the PA at 3:48 a.m. and by the attending physician at 8:03 a.m. on 5/21/18.

5. A review of the policy titled Trauma Team Activation, last approved date 06/2018, revealed in part: "The ED director, ED physician or ED nurse will assign the trauma priority level to trauma patients according to the written criteria for activation. The Priority 2 level can be upgraded at any time but can only be downgraded by a physician after a medical screening exam. Members of the trauma team include ED physician, Primary ED RN, Secondary ED RN, Trauma Surgeon, Anesthesia, OR Team, Radiology, Lab, EKG, Respiratory Therapy, Nursing/Administration and Security. The ED medical doctor (MD) will conduct a primary survey on all Priority 1 and Priority 2 activations upon arrival."

6. A review of the document titled Fairmont Regional Medical Center Priority 1 Trauma Activation Criteria revealed in part: "A priority 1 patient cannot be downgraded at ANY time. DO NOT CANCEL THE SURGEON ON ANY PRIORITY 1. THEY MUST BE CALLED AND HAVE TO SEE THE PATIENT. Emergency Physician's discretion means that a MD or DO, not a PA or NP, can make a patient a P1 even if the patient does not meet the above criteria."

7. An interview was conducted with the Medical Director of the ED on 9/6/18 at 9:39 a.m. When asked about the Priority one (1) (P1) and Priority two (2) (P2) traumas, he stated: "A doctor runs P1 and P2. Midlevels put in orders and assist, documentation portion is the physicians. PA's only do procedures and helps; they don't document unless it is on a procedure they assisted with." When asked what are his expectations of the PA's and physicians when doing P1 and P2, he stated: "PA's help with orders and procedures, physicians do charting and transferring. Patient transfer has to be physician to physician." He stated: "The physician can downgrade a P2, only a physician, and a P1 cannot be downgraded, once seen by the physician everyone can be dismissed. But only when seen by the physician." When asked what creating a document meant, he stated: "They are doing the documenting." He concurred with the findings at 10:19 a.m. that the PA's were not following the ED policies.

B. Based on document review and staff interviews, it was revealed the ED Nursing staff failed to provide care in a safe setting. This failure has the potential to adversely affect the care of all patients.

Findings include:

1. A tour of the ED was conducted on 9/4/18 at 1:19 p.m. The Director of the ED accompanied the surveyor on the tour. The Chief Nursing Officer CNO joined the tour of the ED. ED room one (1) had three (3) IV cathlon accessible to patients and multiple outdated vacutainers. Two (2) blue top vacutainers had an expiration date of 5/31/18, one (1) blue top vacutainer had an expiration date of 2/28/18, six (6) orange top vacutainers had an expiration date of 8/31/18, one (1) orange top vacutainer had an expiration date of 6/30/18, four (4) green top vacutainers had an expiration date of 7/31/18 and two (2) green top vacutainers had an expiration date of 5/31/18. ED room two (2) had two (2) blue top vacutainers with an expiration date of 4/30/18 and one (1) blue top vacutainer with an expiration date of 3/31/18. Trauma room three (3) had two (2) expired pediatric Airtraq for use with pediatric intubation. One (1) Airtraq had an expiration date of 3/2018 and the second Airtraq had an expiration date of 7/2018. Four (4) IV cathlons and one (1) hyperdermic needle were accessible for patients in trauma room three (3). ED room four (4) had fourteen (14) blue top vacutainers with an expiration date of 5/31/18 and one (1) blue top vacutainer with an expiration date of 8/31/18.

2. A review of the pediatric crash cart log for trauma room three (3) for 9/2018 revealed the crash cart was not checked on 9/2/18 and 9/3/18. Further review of the log for 8/2018 revealed the pediatric crash cart was not checked on 8/13/18, 8/15/18, 8/24/18 and 8/25/18.

3. A review of the adult crash cart log for trauma room three (3) for 9/2018 revealed the crash cart was not checked on 9/3/18.

4. A review of the emergency equipment log for trauma room three (3) for 9/2018 revealed the emergency equipment was not checked on 9/2/18. Further review of the log for 8/2018 revealed the emergency equipment was not checked 8/15/18, 8/18/18, 8/19/18 and 8/25/18.

5. A review of the policy titled Code Blue Management of Emergency Equipment, CM-021, last approved date 6/2018, revealed in part: "Checking: All Crash Carts are to be checked once every 24 hours to ensure the integrity of the lock. The initials of the individual checking the Crash Cart will be noted on the Crash Cart check list along with the lock number of the Crash Cart. The individual performing the checks will also check to ensure that required equipment on the top shelf of the cart is in place and operable. The monitor/defibrillator will be checked in accordance with the manufacturer's recommendations. Also the individual will check the oxygen level in the tank and ensure the ambu bag is attached to the side of the cart."

6. During the tour of the ED the Director of the ED and the CNO concurred the ED nursing staff did not follow the policy for Code Blue Management of Emergency Equipment.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on document review and staff interviews, it was revealed the ED department failed to maintain proper storage of soiled supplies to avoid sources and transmission of infection and communicable diseases. This deficient practice has the potential to adversely affect all patients.

Findings include:

1. A tour of the ED was conducted on 9/4/18 at 1:19 p.m. The Director of the ED accompanied the surveyor on the tour. The Chief Nursing Officer (CNO) joined the tour. Two (2) soiled bedside commodes (BSC) were sitting in the hallway against the wall between the lab and the soiled utility room entrance. One (1) soiled IV pump and pole was located in trauma room three (3) for use with the next patient and two (2) soiled portable monitors were located in room four (4) for use with the next patient.

2. A review of the policy titled Cleaning of Reusable Patient Care Equipment, last approved date 07/2016, revealed in part: "After cleaning, IV pumps and poles will be taken to the storage area on the unit. If the IV pump and pole is left in the patient's room for the next patient, place a clean bag over the equipment to signify that it has been cleaned. POTTY CHAIRS and SHOWER CHAIRS- Potty chairs and shower chairs are cleaned between patients by the nursing staff. After patient discharge, the chairs are taken to the soiled utility room and cleaned with hospital approved disfectant. The clean chairs will then be taken to the storage area on the unit. All other reusable patient care equipment must be disinfected between patients per manufacturer's direction. Once the equipment has been cleaned, place a clean plastic bag over the item and place in clean utility room or storage area."

3. During the tour of the ED on 9/4/18 at 1:19 p.m. the Director of the ED and the CNO concurred the equipment was soiled. They stated if the equipment had been cleaned there would be a clean plastic bag placed over the equipment to show it was clean.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
A. Based on document review and staff interviews, it was revealed the facility failed to ensure the Emergency Department (ED) staff were following the ED policies and procedures. This failure was identified in four (4) of ten (10) medical records reviewed for patients #6, 7, 9 and 10.. This failure has the potential to adversely affect all patient care.

Findings include:

1. A review of the medical record for patient #6 revealed a priority two (2) trauma was called by the triage nurse at 10:19 p.m. on 6/20/18. Patient #6 was seen by the provider at 10:24 p.m. on 6/20/18. The ED physician documentation was dictated/created by the Physician Assistant (PA) at 10:35 p.m. on 6/20/18 and electronically signed by the PA at 2:15 a.m. on 6/20/18. The attending physician electronically signed this documentation at 6:50 a.m. on 6/21/18.

2. A review of the medical record for patient #7 revealed a priority one (1) trauma was called by the triage nurse at 1:31 a.m. on 6/14/18. Patient #7 was seen by the provider at 1:42 a.m. The ED physician documentation was created by the PA at 2:13 a.m. on 6/14/18. The PA stated in his initial comments: "Patient was immediately sent to the scanner and West Virginia University was contacted for a priority 1 transfer emergency department to emergency department." Further review revealed the PA stated in the medical decision making section: "Emergency 911 transfer has been ordered to West Virginia University spoke with the accepting physician at West Virginia University. His name is on chart. Patient stable for transfer." This ED physician documentation created by the PA was electronically signed by the PA at 2:23 a.m. on 6/14/18. An addendum to this ED physician documentation was created by the PA at 2:32 a.m. on 6/14/18 and electronically signed by the PA at 2:32 a.m. and electronically signed by the attending physician at 6:45 a.m. on 6/14/18. Another ED physician documentation was created by the attending physician at 2:14 a.m. on 6/14/18 and electronically signed by the attending physician at 2:20 a.m. on 6/14/18. No documentation of contact to West Virginia University ED was noted in the attending physician documentation. The PA documented the transfer of patient #7 to another facility.

3. A review of the medical record for patient #9 revealed a priority one (1) trauma was called by the triage nurse at 10:56 p.m. on 6/3/18. Patient #9 was seen by the provider at 11:04 p.m. on 6/3/18. The ED physician documentation was created by the PA at 12:02 a.m. on 6/4/18. The PA stated in the initial comments: "A priority one (1) trauma was called before a provider could assess the patient. This does not meet the criteria for a priority one (1) trauma." This ED Physician Documentation was electronically signed by the PA at 12:09 a.m. on 6/4/18 and electronically signed by the attending physician at 6:31 a.m. on 6/4/18.

4. A review of the medical record for patient #10 revealed a priority two (2) trauma was called by the triage nurse at 1:46 a.m. on 5/21/18. Patient #10 was seen by the provider at 1:49 a.m. on 5/21/18. The ED physician documentation was created by the PA at 1:51 a.m. on 5/21/18. This ED physician documentation was electronically signed by the PA at 3:23 a.m. on 5/21/18. An addendum to this documentation was created by the PA at 3:48 a.m. on 5/21/18. This Addendum was electronically signed by the PA at 3:48 a.m. and by the attending physician at 8:03 a.m. on 5/21/18.

5. A review of the policy titled Trauma Team Activation, last approved date 06/2018, revealed in part: "The ED director, ED physician or ED nurse will assign the trauma priority level to trauma patients according to the written criteria for activation. The Priority 2 level can be upgraded at any time, but can only be downgraded by physician after medical screening exam. Members of the trauma team include: ED physician, Primary ED RN, Secondary ED RN, Trauma Surgeon, Anesthesia, OR Team, Radiology, Lab, EKG, Respiratory Therapy, Nursing/Administration and Security. The ED medical doctor (MD) will conduct a primary survey on all Priority 1 and Priority 2 activations upon arrival."

6. A review of the document titled Fairmont Regional Medical Center Priority 1 Trauma Activation Criteria revealed in part: "A priority 1 Patient cannot be downgraded at ANY time. DO NOT CANCEL THE SURGEON ON ANY PRIORITY 1. THEY MUST BE CALLED AND HAVE TO SEE THE PATIENT. Emergency Physician's discretion means that a MD or DO, not a PA or NP, can make a patient a P1 even if the patient does not met the above criteria."

7. An interview was conducted with the Medical Director of the ED on 9/6/18 at 9:39 a.m. When asked about the Priority 1 (P1) and Priority 2 (P2) traumas, he stated: "A doctor runs P1 and P2. Midlevels put in orders and assist, documentation portion is the physicians. PA's only does procedures and helps, they don't document unless it is on a procedure they assisted with." When asked what are his expectations of the PA's and physicians when doing P1 and P2, he stated, "PA's helping with orders and procedures, physicians doing charting and transferring. Patient transfer has to be physician to physician. The physician can downgrade a P2, only a physician and a P1 cannot be downgraded, once seen by the physician everyone can be dismissed. But only when seen by the physician." When asked what creating a document meant, he stated: "They are doing the documenting." He concurred with the findings at 10:19 a.m. the PA's were not following the ED policy and procedures.

B. Based on document review and staff interviews it was revealed the ED Nursing staff failed to follow the ED policy and procedures. This failure has the potential to adversely affect the care of all patients.

Findings include:

1. A tour of the ED was conducted on 9/4/18 at 1:19 p.m. The Director of the ED accompanied the surveyor on the tour. The CNO joined the tour of the ED. ED room one (1) had three (3) IV cathlons accessible to patients and multiple outdated vacutainers. Two (2) blue top vacutainers had an expiration date of 5/31/18, one (1) blue top vacutainer had an expiration date of 2/28/18, six (6) orange top vacutainers had an expiration date of 8/31/18, one (1) orange top vacutainer had an expiration date of 6/30/18, four (4) green top vacutainers had an expiration date of 7/31/18 and two (2) green top vacutainers had an expiration date of 5/31/18. ED room two (2) had two (2) blue top vacutainers with an expiration date of 4/30/18 and one (1) blue top vacutainer with an expiration date of 3/31/18. Trauma room three (3) had two (2) expired pediatric Airtraq for use for pediatric intubation. One (1) Airtraq had an expiration date of 3/2018 and the second Airtraq had an expiration date of 7/2018. Four (4) IV cathlons and one (1) hyperdermic needle were accessible to patients in trauma room three (3). ED room four (4) had fourteen (14) blue top vacutainers with an expiration date of 5/31/18 and one (1) blue top vacutainer with an expiration date of 8/31/18.

2. A review of the pediatric crash cart log for trauma room three (3) for 9/2018 revealed the crash cart was not checked on 9/2/18 and 9/3/18. Further review of the log for 8/2018 revealed the crash cart was not checked on 8/13/18, 8/15/18, 8/24/18 and 8/25/18.

3. A review of the adult crash cart log for trauma room three (3) for 9/2018 revealed the crash cart was not checked on 9/3/18.

4. A review of the emergency equipment log for trauma room three (3) for 9/2018 revealed the emergency equipment was not checked on 9/2/18. Further review of the log for 8/2018 revealed the emergency equipment was not checked 8/15/18, 8/18/18, 8/19/18 and 8/25/18.

5. A review of the policy titled Code Blue Management of Emergency Equipment, CM-021, last approved date 6/2018, revealed in part: "Checking: All Crash Carts are to be checked once every 24 hours to ensure the integrity of the lock. The initials of the individual checking the Crash Cart will be noted on the Crash Cart check list along with the lock number of the Crash Cart. The individual performing the checks will also check to ensure that required equipment on the top shelf of the cart is in place and operable. The monitor/defibrillator will be checked in accordance with the manufacturer's recommendations. Also the individual will check the oxygen level in the tank and ensure the ambu bag is attached to the side of the cart."

6. During the tour of the ED the Director of the ED and the CNO concurred the ED nursing staff did not follow the policy and procedures for Code Blue Management of Emergency Equipment.