WEIRTON, WV - Federal inspectors found multiple safety violations at Weirton Medical Center during a June 2024 survey, including dangerously hot water that could cause severe burns within minutes and systemic failures in medication management and patient nutrition oversight.
Scalding Water Temperatures Put Residents at Risk
The most immediate safety concern identified involved water temperatures that far exceeded safe limits throughout the facility. Inspectors documented water temperatures reaching 124 degrees Fahrenheit in a shower room sink and 123.2 degrees Fahrenheit in a resident room sink. In another location, water reached 120.5 degrees Fahrenheit.
These temperatures pose serious burn risks for vulnerable nursing home residents. Water heated to 124 degrees can cause third-degree burns in just three minutes, while 120-degree water can produce the same severe injuries within five minutes. For elderly residents with compromised circulation, thinner skin, or cognitive impairments that might delay their response to hot water, the risk of serious injury increases significantly.
Third-degree burns represent the most severe type of thermal injury, penetrating through all skin layers and permanently destroying tissue. These injuries often appear as dry, leathery skin that may be charred or display white, brown, or black patches. The damage is typically painless due to nerve destruction, though surrounding areas may experience intense pain from accompanying first- and second-degree burns.
"Maintenance Worker #26 stated he knew it was undesirable to have a water temperature at or above 120.0 degrees Fahrenheit," according to the inspection report, indicating staff awareness of the problem without corrective action.
Industry standards require nursing homes to maintain water temperatures between 100-110 degrees Fahrenheit to prevent scalding injuries. Facilities must install mixing valves, temperature-limiting devices, and conduct regular monitoring to ensure compliance. The Director of Nursing confirmed that maintenance staff would immediately address all water temperatures to ensure resident safety.
Inadequate Pain Management Protocols
Inspectors found significant deficiencies in pain management for residents requiring ongoing medical treatment. One resident reported receiving medication for back pain and arthritis but stated that "his pain levels were not always under control" and had requested a doctor visit due to inadequate pain relief.
Medical record review revealed the resident had been prescribed two pain medications with specific usage guidelines: Oxycodone 5mg every six hours for severe pain, and Acetaminophen 650mg every six hours for mild pain rated 1-3 on the standard pain scale.
However, nursing staff consistently administered the weaker medication when stronger pain relief was medically indicated. On three documented occasions, staff gave Acetaminophen for pain levels well above the prescribed threshold:
- Pain level 10 (maximum) treated with Acetaminophen instead of Oxycodone - Pain level 6 treated with the weaker medication - Pain level 4 treated inappropriately
This represents a fundamental breakdown in pain assessment and medication administration protocols. Proper pain management requires staff to accurately assess pain levels using standardized scales and administer appropriate medications based on physician orders and clinical protocols.
Inadequate pain control can lead to multiple medical complications including delayed healing, increased risk of infection, elevated blood pressure and heart rate, depression, decreased mobility, and reduced quality of life. For residents with chronic conditions like arthritis and back pain, appropriate pain management is essential for maintaining function and preventing deterioration.
The Director of Nursing acknowledged the inappropriate medication administration during the inspection, confirming that stronger pain medication should have been given based on the documented pain levels.
Nutrition Monitoring Failures
The facility failed to provide adequate nutritional oversight for residents requiring specialized dietary management. Inspectors observed a diabetic resident whose lunch tray remained untouched during multiple meal observations, with no staff assistance offered or provided.
Medical records showed the resident had physician orders for a diabetic regular diet, but the facility failed to conduct required nutritional assessments. No admission weight was documented, nor was the mandated seven-day nutritional evaluation completed. Meal intake records revealed the resident consumed only 0-25% of meals, indicating severe undernourishment.
For diabetic residents, consistent nutrition intake is critical for blood sugar management and overall health maintenance. Inadequate food intake can lead to hypoglycemia (dangerous low blood sugar), muscle wasting, impaired wound healing, increased infection risk, and accelerated decline in overall health status.
Federal regulations require nursing homes to conduct comprehensive nutritional assessments within one week of admission, obtain baseline weights, monitor ongoing intake, and provide assistance as needed. The facility's failure to implement these basic protocols represents a significant gap in resident care standards.
Medication Storage and Review Deficiencies
Inspectors identified multiple problems with medication management systems that could compromise drug effectiveness and resident safety. The medication room lacked proper temperature monitoring, with no devices installed to track environmental conditions that could affect drug stability.
Many medications require specific storage temperatures to maintain their therapeutic effectiveness. Exposure to excessive heat, humidity, or temperature fluctuations can reduce drug potency, alter chemical composition, or create harmful degradation products. Without proper monitoring, residents may receive medications that have lost effectiveness or become potentially dangerous.
Additionally, the facility failed to ensure physicians responded appropriately to monthly pharmacist reviews. In one case, a consulting pharmacist identified concerns about three psychoactive medications prescribed without documented mental health diagnoses - Duloxetine, Mirtazapine, and Lorazepam. Despite facility policies requiring physician response within seven days, no action was documented nearly a month after the pharmacist's recommendations.
This breakdown in the medication review process prevents appropriate evaluation of drug necessity, potential interactions, and optimization of therapeutic regimens. Regular pharmacist reviews serve as an essential safety mechanism to identify inappropriate prescribing, reduce polypharmacy risks, and ensure medications align with residents' current clinical conditions.
Additional Issues Identified
The inspection revealed other compliance failures affecting facility operations:
Quality Assurance Oversight: The facility failed to conduct required quarterly Quality Assessment and Assurance meetings during the first quarter of 2024, representing a breakdown in systematic quality monitoring and improvement processes.
Documentation Standards: Multiple instances of incomplete or missing documentation were noted across various care areas, indicating systemic issues with record-keeping and regulatory compliance.
These violations collectively demonstrate significant gaps in the facility's safety protocols, clinical oversight, and regulatory compliance systems. The combination of immediate physical hazards like scalding water temperatures and systemic failures in medication and nutrition management represents serious risks to resident health and safety that require immediate corrective action.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Weirton Medical Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
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