Byrd Regional Hospital

“DISCHARGE PLANNING CFR(s): 482.43 The hospital must have in effect a discharge planning process that focuses on the patient goals and treatment preferences and includes the patient and his or her caregivers support person(s) in the discharge planning for post-discharge care. The discharge planning process and the discharge plan must be consistent with the patient’s goals for care and his or her treatment preferences, ensure an effective transition of the patient from hospital to post-discharge care, and reduce the factors leading to a preventable hospital readmissions This Condition is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to meet the requirements of the Condition of Participation for Discharge Planning as evidenced by failure to ensure discharge planning was provided for all patients, began at admission, and ongoing discharge planning/discharge plans were documented in the patient’s medical record for 2 (#1, #2) of 3 patient records reviewed (see findings A-0800).”

“DATA COLLECTION & ANALYSIS CFR(s): 482.21(a), (b)(1),(b)(2)(i), (b)(3) (a) Program Scope (1) The program must include, but not be limited to, an ongoing program that shows measurable improvement in indicators for which there is evidence that it will improve health outcomes ... (2) The hospital must measure, analyze, and track quality indicators ... and other aspects of performance that assess processes of care, hospital service and operations. (b)Program Data (1) The program must incorporate quality indicator data including patient care data, and other relevant data such as data submitted to or received from Medicare quality reporting and quality performance programs, including but not limited to data related to hospital readmissions and hospital-acquired conditions. (2) The hospital must use the data collected to-- (i) Monitor the effectiveness and safety of services and quality of care; and .... (3) The frequency and detail of data collection must be specified by the hospital’s governing body. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure the Quality Assessment and Performance Improvement program measured, analyzed, and tracked quality indicators to monitor the safety and effectiveness of hospital services and operations. This deficient practice was evidenced by failing to ensure results of case management monthly audits were submitted to the Quality Improvement Council as documented in the Organization-wide Quality Assessment and Performance Improvement Program 2025. Findings: Review of the hospital’s Organization-wide Quality Assessment and Performance Improvement Program 2025 revealed in part, “V. Communication and Reporting: To coordinate the quality improvement activities throughout the organization, the QMRC [Quality Management/Regulatory Compliance] will receive and have access to all QI [quality improvement] information. Department leaders will communicate their quality activities and performance to their Employees, to the Senior Leader to whom they report, and/or to the Quality Coordinator (due by the 15th of the following month), using the approved reporting forms and format. Measurement and assessment activities are reported to the Quality Improvement Council, Medical Executive Committee, and to the Governing Board on at least a quarterly basis.” Review of the Compliance Committee Meeting Minutes dated 01/13/2026 failed to reveal case management monthly audit results being reported. In a phone interview on 03/03/2026 at 3:17 PM, S8CMD confirmed she reviews medical records monthly for discharge planning. S8CMD stated audit results are reported to their corporate office. S8CMD confirmed she does not report audit results to the hospital wide QAPI. In an interview on 03/03/2026 at 3:25 PM, S5QD confirmed case management monthly audit results were not reported in the compliance committee meeting dated 01/13/2026.”

“CONTENT OF RECORD: HISTORY & PHYSICAL CFR(s): 482.24(c)(4)(i)(A) All records must document the following, as appropriate: (i) Evidence of-- (A) A medical history and physical examination completed and documented no more than 30 days before or 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services, and except as provided under paragraph (c)(4)(i)(C) of this section. The medical history and physical examination must be placed in the patient’s medical record within 24 hours after admission or registration, but prior to surgery or a procedure requiring anesthesia services. This Standard is not met as evidenced by: 44763 Based on record review and interview, the hospital failed to ensure each admitted patient had a history and physical performed no more than 30 days before or 24 hours after admission. This deficient practice was evidenced by failure to complete the history and physical within 24 hours after admission for 1 (#3) of 3 patient records reviewed. Findings: Review of the Medical Staff Bylaws revealed in part, “3.3 Basic Responsibilities of Staff Membership: 3.3 (o) Comply with the following requirements concerning history and physical examinations: Each patient admitted for inpatient care shall have complete admission history and physical examination recorded by a qualified physician (or other licensed independent practitioner who has been credentialed and granted privileges to perform a history and physical examination) within twenty-four (24) hours of admission and prior to any surgical procedure or invasive diagnostic procedure requiring anesthesia.” Review of Patient #3’s medical record revealed Patient #3 was admitted on 03/01/2026 at 2:46 AM. Further review of the medical record failed to reveal a completed history and physical. In an interview on 03/02/2026 at 2:08 PM, S2ACD confirmed Patient #3’s history and physical was not completed by the physician within 24 hours of admission.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 44763 Based on observation and interview, the hospital failed to have an effective infection prevention and control program as evidenced by failure to ensure clean linen was stored appropriately. Findings: Review of the hospital’s policy titled “Infection Control Guidelines for Linen Handling and Processing”, revised date 03/19/2025, revealed in part, E. Transportation and storage of clean linen: Stored linen is to remain covered until distributed for patient use. Linen closet doors must be kept closed. Linen should be stored at least 8 inches off the floor. Tour of the 2nd floor inpatient units on 03/02/2026 at 10:41 AM - 11:40 AM accompanied by S1CNO, S5QD, and S6RM revealed a storage room. Observation of the storage room revealed 9 shelving units containing clean patient linens which were uncovered, exposed to particles in the air. Further observation revealed dust mop heads stored next to white, orange stripe towels. There were patient gowns lying on the floor in the corner between the shelving units. There were towels stacked in another corner between the shelving units. There were blue cleaning towels stacked on the floor in front of one of the shelving units. There were 5 white cardboard boxes stored on the floor underneath the shelving units. In an interview during the observation, S7HS confirmed the white, orange stripe towels were used in the kitchen. In an interview during the observation, S1CNO confirmed the above stated findings.”

“DISCHARGE PLANNING - EARLY IDENTIFICATION CFR(s): 482.43(a) The hospital’s discharge planning process must identify at an early stage of hospitalization those patients who are likely to suffer adverse health consequences upon discharge in the absence of adequate discharge planning and must provide a discharge planning evaluation for those patients so identified as well as for other patients upon the request of the patient, patient’s representative, or patient’s physician. This Standard is not met as evidenced by: 44763 Based on record reviews and interviews, the hospital failed to ensure discharge planning was provided for all patients, began at admission, and ongoing discharge planning/discharge plans were documented in the patient’s medical record for 2 (#1, #2) of 3 patient records reviewed. Findings: Review of the hospital’s policy titled “CM Plan for Discharge Planning”, date revised 07/22/2019, revealed in part, “Discharge Planning is a systematic, organized and interdisciplinary approach to identify and provide for post discharge needs of all patients and their families. It is the policy of Byrd Regional Hospital to provide an interdisciplinary hospital-wide mechanism for providing post discharge continuity of care to patients and their families.” Patient #1 Review of Patient #1’s medical record revealed Patient #1 was admitted on 01/31/2026 (Saturday) and was discharged on 02/01/2026 (Sunday). Review of the history and physical dated 01/31/2026 at 5:20 PM revealed in part, Plan: admit to inpatient hospice and will discuss further with family about transfer over to them in the next few days. Further review of Patient #1’s medical record failed to reveal initiation of discharge planning. In an interview on 03/03/2026 at 1:43 PM, S3RN confirmed this was over the weekend and case management personnel do not work in the hospital on the weekend. S3RN stated if the patient would have been admitted during the week, she would have seen Patient #1 and conducted the initial discharge planning interview. In an interview on 03/03/2026 at 1:49 PM, S2ACD confirmed there was no documentation of discharge planning included in Patient #1’s medical record. Patient #2 Review of Patient #2’s medical record revealed Patient #2 was admitted on 01/09/2026 (Friday) and was discharged on 01/11/2026 (Sunday). Review of the physician orders revealed in part, 01/11/2026 10:44 AM Order Comments: patient needs referral for biopsy of left lingular mass noted on chest CT and he needs an outpatient cardiac echo. Further review of Patient #2’s medical record failed to reveal discharge planning. In an interview on 03/03/2026 at 9:40 AM, S4RN confirmed case management only works Monday through Friday. In an interview on 03/03/2026 at 10:13 AM S3RN stated the order should have been put in as a case management consult. S3RN stated the order was put in as a nursing order. S3RN stated if entered as case management consult, it would have been automatically sent to case management. S3RN stated case management would have contacted the patient or family after discharge and then sent out the referrals. S3RN confirmed case management only works Monday through Friday. S3RN stated Patient #2 was discharged on Sunday. S3RN confirmed case management did not see Patient #2 because it was a weekend. S3RN stated it looks like “we missed him altogether”. S3RN confirmed there was no documentation in Patient #2’s medical record from case management for discharge planning. S3RN confirmed she is the only case manager that is seeing patients currently.”