Webster Memorial Hospital

“LIFE SAFETY FROM FIRE CFR(s): §485.623(c) Standard: Life Safety From Fire (1) Except as otherwise provided in this section: (i) The CAH must meet the applicable provisions and must proceed in accordance with the Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4.) (ii) Notwithstanding paragraph (d)(1)(i) of this section, corridor doors and doors to rooms containing flammable or combustible materials must be provided with positive latching hardware. Roller latches are prohibited on such doors. This Standard is not met as evidenced by: 38626 Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 101 and 70. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 0. Findings include: a) During the facility inspection tour conducted on 10/29/24 at 10:55 a.m. revealed one electrical junction box missing a punch out and five missing cover plates. b) Interview on 10/29/24 at approximately 1:00 p.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 10/29/24.”

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 43434 The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. Based on document review and staff interviews, the facility failed to meet the requirements of 42CFR 485.627, as evidenced by the facility’s failure to review, revise and update facility policies annually and as needed, including but not limited to 485.627 (a). Findings: An interview was conducted on 10/30/24 at 12:22 p.m. with Staff #1 and Staff #3 regarding the temporary morgue. Staff #1 and Staff #3 were asked about the fact that the policy for the temporary morgue had never been updated in the last fourteen (14) years. Staff #3 stated, “Vandalia and Davis wanted us to put a hold on updating the policies until the merger was completed so all everything would be a part of Vandalia’s policy system.” When questioned how a hold on policy review currently would have anything to do with the fact that the policy has never been reviewed or revised since it’s effective date of 3/2010. Staff #3 stated, “It doesn’t, it’s inexcusable, it wasn’t done.” Staff #1 stated that there was no evidence found in QUAPI meeting minutes that reflects that the morgue policies were reviewed or revised.” When asked if Staff #1 and Staff #3 were aware that the “Oversight Committee” policy states that all WCMH Policy procedure manuals will be reviewed annually, Staff #1 and Staff #3 stated, “Yes.” Staff #1 was asked if the Procedure Room policy and the Trash Receptacle policy that had been requested during the survey had been updated after the policy was requested? Staff #1 stated, “Yes.” A review of the policy, titled “Oversight Committee” dated 4/2019 states, “Purpose: Oversee WCMH Policy and Procedure. Policy: It is the policy of Webster County Memorial Hospital (WCMH) to ensure that policies/procedures are appropriate for this institution, meet current standard and are put in place in the appropriate areas of this facility. Procedure: There will be a committee called ‘The Policy/Procedure Oversight Committee.’ This Committee will review all Webster County Memorial Hospital policies/procedures. All WCMH Policy procedure manuals will be reviewed annually.” A review of the policy, titled “SET UP OF TEMPORARY MORGUE” dated 03/2010 and never reviewed states, “Upon activation of the Webster County Memorial Hospital (WCMH) Incident Command System (ICS) and as instructed through the ICS, assigned personnel will set up a temporary morgue in the Emergency Medical Services (EMS) Department located on the second floor of the hospital or other designated area. PROCEDURE: Upon activation of the ICS and appointment by the Medical Care Branch Director or Clinical Support Services Unit Leader, WCMH personnel will provide morgue services. A morgue will be set up in the EMS Department located on the second floor of the hospital (Room #202).” A review of the policy, titled “PROCEDURE ROOM” dated 2/1/05 and revised 10/24, after the policy was requested by surveyor states, “Policy: Protocol for bodies being checked into the morgue: Emergency Department, Med Surg floor or from other sources. Procedure: When a patient death occurs within Webster Memorial Hospital, the body can be transferred to the second floor procedure room to await transfer to funeral home, ME, or CORE if time is a factor. The pronouncement of death must minimally be completed by the attending physician or by one of the staff physicians that are in the Emergency Department. In unusual circumstances when bodies are brought in from the outside, the request will be discussed with Emergency Department staff and OES. Under no circumstance should a body be released without presence of nursing personnel. We are asked to receive bodies into out procedure room that are going to become the responsibility of the medical examiner. These bodies are held on a temporary basis until the examiner is available to receive them. Prior to placing body in procedure room, temperature is set to lowest setting.” Based on the findings, the facility failed to comply with the requirements of 42CFR 485.627.”

“LIFE SAFETY CODE STANDARD CFR(s): NFPA 101 Electrical wiring and equipment is in accordance with NFPA 70, National Electrical Code. 9.1.2 This Standard is not met as evidenced by: 38626 Based on observation and staff interview, the facility failed to ensure that electrical wiring and equipment shall be in accordance with NFPA (National Fire Protection Association) 101 and 70. This deficient practice could affect all residents, staff, and visitors in the areas referenced. Facility census 0. Findings include: a) During the facility inspection tour conducted on 10/29/24 at 10:55 a.m. revealed one electrical junction box missing a punch out and five missing cover plates. b) Interview on 10/29/24 at approximately 1:00 p.m. with the Facilities Maintenance Director verified these findings. The findings were were also acknowledged by the Administrator at the exit interview on 10/29/24.”