WELCH COMMUNITY HOSPITAL (WELCH, WV) Detailed Hospital Profile

Complaint Deficiency

Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Some
A two-hour-resistant firewall in common walls
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Exits that are accessible at all times
- Harm: Minimal harm or potential for actual harm
- Scope: Few
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Few
A two-hour-resistant firewall in common walls
- Harm: Potential for minimal harm
- Scope: Many
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Potential for minimal harm
- Scope: Many
Properly installed electrical wiring and equipment
- Harm: Potential for minimal harm
- Scope: Some
Give each resident a notice of rights, rules, services and charges. Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for
- Harm: Potential for minimal harm
- Scope: Many
Allow residents to easily view the results of the nursing home's most recent survey
- Harm: Potential for minimal harm
- Scope: Some
Tell the resident or the resident's representative in writing how long the nursing home will hold the resident's bed
- Harm: Potential for minimal harm
- Scope: Some
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Make sure that each resident's drug regimen is free from unnecessary drugs; 2) Each resident's entire drug/medication is managed and monitored to achieve highest well being
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents are safe from serious medication errors
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop policies and procedures for influenza and pneumococcal immunizations
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Potential for minimal harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Put firmly secured handrails on each side of hallways
- Harm: Potential for minimal harm
- Scope: Some
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Give the resident's representative the ability to exercise the resident's rights
- Harm: Minimal harm or potential for actual harm
- Scope: Few
1) Protect current or future residents from giving up their Medicaid or Medicare benefits; or 2) follow federal rules for admissions
- Harm: Potential for minimal harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Review or revise the resident's care plan after any major change in a resident's physical or mental health
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Encode and automate the resident's assessment data
- Harm: Potential for minimal harm
- Scope: Many
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, and receive proper services to prevent urinary tract infections and restore normal bladder function
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Make sure that each resident gets a nutritional and well balanced diet, unless it is not possible to do so
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Have enough nurses to care for every resident in a way that maximizes the resident's well being
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Hire sufficient dietary support personnel
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that special or therapeutic diets are ordered by the attending doctor
- Harm: Potential for minimal harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Exits that are accessible at all times
- Harm: Potential for minimal harm
- Scope: Many
An approved installation, maintenance and testing program for fire alarm systems
- Harm: Potential for minimal harm
- Scope: Many
Walls or barriers that prevent smoke from passing through and would resist fire for at least one hour
- Harm: Potential for minimal harm
- Scope: Many
Construction that can resist fire for one hour or an approved fire extinguishing system
- Harm: Potential for minimal harm
- Scope: Some
Properly hold, secure and manage each resident's personal money which is deposited with the nursing home
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Keep each resident free from physical restraints, unless needed for medical treatment
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Protect each resident from all abuse, physical punishment, and being separated from others
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Provide care for residents in a way that keeps or builds each resident's dignity and respect of individuality
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Provide activities to meet the interests and needs of each resident
- Harm: Immediate jeopardy to resident health or safety
- Scope: Few
Ensure the activities program is directed by a qualified professional
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Provide medically-related social services to help each resident achieve the highest possible quality of life
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Conduct initial and periodic assessments of each resident's functional capacity
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Allow the resident the right to participate in the planning or revision of the resident's care plan
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that residents receive proper treatment and assistive devices to maintain their vision and hearing
- Harm: Minimal harm or potential for actual harm
- Scope: Few
Make sure that the nursing home area is free from accident hazards and risks and provides supervision to prevent avoidable accidents
- Harm: Actual harm
- Scope: Some
Post nurse staffing information/data on a daily basis
- Harm: Potential for minimal harm
- Scope: Many
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Store, cook, and serve food in a safe and clean way
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Have a program that investigates, controls and keeps infection from spreading
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Keep all essential equipment working safely
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Make sure that a working call system is available in each resident's room or bathroom and bathing area
- Harm: Minimal harm or potential for actual harm
- Scope: Some
Be administered in an acceptable way that maintains the well-being of each resident
- Harm: Actual harm
- Scope: Some
Operate and provide services according to Federal, State, and local laws and professional standards
- Harm: Potential for minimal harm
- Scope: Many
Keep clinical record information safe, so that it will not be lost, destroyed or used by the wrong person
- Harm: Minimal harm or potential for actual harm
- Scope: Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action
- Harm: Actual harm
- Scope: Some

Hospital Consumer Assessment of Healthcare Providers

Number of Completed Surveys:: Between 100 and 299
Survey Response Rate: 27%

How often did nurses communicate well with patients?

Sometimes or never

Here:	3%
West Virginia:	6%

Usually

This Hospital:	12%
West Virginia:	17%

Always

This Hospital:	85%
West Virginia:	77%

How often did doctors communicate well with patients?

Sometimes or never

Here:	4%
State:	4%

Usually

Here:	13%
West Virginia:	14%

Always

This Hospital:	83%
West Virginia:	82%

How often did patients receive help quickly from hospital staff?

Sometimes or never

This Hospital:	4%
State:	12%

Usually

Here:	12%
State:	23%

Always

This Hospital:	84%
West Virginia:	65%

How often was patients' pain well controlled?

Sometimes or never

Here:	5%
State:	8%

Usually

This Hospital:	17%
West Virginia:	23%

Always

Here:	78%
State:	69%

How often did staff explain about medicines before giving them to patients?

Sometimes or never

Here:	19%
West Virginia:	20%

Usually

This Hospital:	15%
West Virginia:	18%

Always

Here:	66%
West Virginia:	62%

How often were the patients' rooms and bathrooms kept clean?

Sometimes or never

Here:	4%
State:	9%

Usually

This Hospital:	16%
State:	18%

Always

This Hospital:	80%
State:	73%

How often was the area around patients' rooms kept quiet at night?

Sometimes or never

This Hospital:	4%
West Virginia:	13%

Usually

This Hospital:	24%
State:	32%

Always

This Hospital:	72%
West Virginia:	55%

Were patients given information about what to do during their recovery at home?

Yes

Here:	85%
State:	83%

Here:	15%
West Virginia:	17%

How do patients rate the hospital overall on a scale from 0 (lowest) to 10 (highest)?

6 or lower

Here:	11%
State:	11%

7 or 8

Here:	19%
State:	24%

9 or 10

Here:	70%
West Virginia:	65%

Would patients recommend the hospital to friends and family?

This Hospital:	4%
State:	6%

Yes, probably

Here:	24%
West Virginia:	29%

Yes, definitely

This Hospital:	72%
West Virginia:	65%

Use of Medical Imaging

Outpatients who had a follow-up mammogram or ultrasound within 45 days after a screening mammogram.

This Hospital:	27.300%
State:	8.958%

Outpatient CT scans of the abdomen that were combination (double) scans.

Here:	0.019%
State:	0.275%

Outpatients with brain CT scans who got a sinus CT scan at the same time

This Hospital:	1.200%
State:	3.183%

Quality Measures

Percent of long-stay residents who received an antipsychotic medication

This Hospital:	33.3%
State:	21.3%

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Chronic Obstructive Pulmonary Disease with Major Complications

Average Covered Charges

Here:	$6,497
State:	$16,204

Average Total Payments

Here:	$13,482
State:	$7,123

Number of discharges: 11

Here:	12.22%
State:	3.14%

Chronic Obstructive Pulmonary Disease without Complications

Average Covered Charges

Here:	$7,237
State:	$9,702

Average Total Payments

This Hospital:	$8,680
State:	$4,286

Number of discharges: 17

This Hospital:	18.89%
West Virginia:	3.30%

Esophagitis, Gastroent and Miscellaneous Digestive Disorders without Major Complications

Average Covered Charges

Here:	$10,449
West Virginia:	$11,121

Average Total Payments

Here:	$9,034
State:	$4,399

Number of discharges: 11

This Hospital:	12.22%
West Virginia:	3.99%

Kidney and Urinary Tract Infections without Major Complications

Average Covered Charges

This Hospital:	$7,101
West Virginia:	$10,257

Average Total Payments

Here:	$9,264
West Virginia:	$4,701

Number of discharges: 11

This Hospital:	12.22%
West Virginia:	3.45%

Misc Disorders of Nutrition, Metabolism, Fluids or Electrolytes without Major Complications

Average Covered Charges

Here:	$6,433
West Virginia:	$9,782

Average Total Payments

This Hospital:	$8,117
West Virginia:	$4,200

Number of discharges: 14

Here:	15.56%
West Virginia:	1.96%

Simple Pneumonia and Pleurisy with Complications

Average Covered Charges

This Hospital:	$9,900
State:	$14,392

Average Total Payments

This Hospital:	$12,023
State:	$6,029

Number of discharges: 12

Here:	13.33%
State:	3.71%

Simple Pneumonia and Pleurisy without Complications

Average Covered Charges

This Hospital:	$8,236
State:	$9,911

Average Total Payments

This Hospital:	$8,520
State:	$4,263

Number of discharges: 14

This Hospital:	15.56%
West Virginia:	1.55%

Process of Care

Heart Attack

Average number of minutes before outpatients with chest pain or possible heart attack got an ECG

This Hospital:	38
West Virginia:	11

Outpatients with chest pain or possible heart attack who got aspirin within 24 hours of arrival

Here:	89.0%
State:	96.9%

Heart Failure

Percent of patients who were given an evaluation of Left Ventricular Systolic Dysfunction (LVSD)

This Hospital:	21.0%
West Virginia:	98.4%

Percent of Patients Given Discharge Instructions

Here:	26.0%
West Virginia:	91.6%

Pneumonia

Percent of Patients Given Initial Antibiotic(s) within 6 Hours After Arrival

Here:	91.0%
West Virginia:	95.2%

Percent of Patients Whose Initial ER Blood Culture Was Performed Prior To Administration Of First Dose Of Antibiotics

This Hospital:	70.0%
State:	96.0%

Percent of Patients Given Smoking Cessation Advice/Counseling

This Hospital:	85.0%
State:	98.3%

Percent of Patients Given the Most Appropriate Initial Antibiotic(s)

This Hospital:	86.0%
West Virginia:	93.3%

Percent of Patients Assessed and Given Influenza Vaccination

Here:	59.0%
West Virginia:	93.2%

Percent of Patients Assessed and Given Pneumococcal Vaccination

This Hospital:	61.0%
West Virginia:	95.7%

Surgery

Percent of Surgery Patients who got treatment at right time (within 24 hours before or after surgery) to help prevent blood clot

This Hospital:	60.0%
West Virginia:	95.5%

Percent of Surgery Patients whose doctors ordered treatments to prevent blood clots after certain types of surgeries

Here:	60.0%
West Virginia:	96.5%

Percent of Surgery Patients needing hair removed from the surgical area before surgery who had hair removed using a safer method

Here:	95.0%
West Virginia:	99.8%

Patients having surgery who were actively warmed in the operating room or whose body temperature was near normal

This Hospital:	38.0%
State:	98.9%

Outcome of Care

30-Day Mortality Rates from Pneumonia

This Hospital:	15.4%
State:	12.3%

30-Day Readmission Rates from Pneumonia

This Hospital:	18.6%
West Virginia:	19.6%

WELCH COMMUNITY HOSPITAL - WELCH, WV

Complaint Deficiency

Hospital Consumer Assessment of Healthcare Providers

Use of Medical Imaging

Quality Measures

Inpatient Prospective Payment System (IPPS) - Medicare Provider Charge Data

Process of Care

Heart Attack

Heart Failure

Pneumonia

Surgery

Outcome of Care

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