HospitalInspections.org

Based on document review and interview it was revealed the governing body (GB) failed to ensure abuse and neglect trends were analyzed and performance improvement processes put in place as needed. This creates the potential for harm to all patients.

Findings include:

1. Review of a document titled, "QAPI Committee Agenda-September 28, 2021 (rescheduled from 9/23/21 Reporting Period is for AUGUST 2021" revealed it includes rates of alleged staff abuse broken down by month from January 2021 through August 2021. From January 2021 to February 2021 the number of alleged staff abuse cases rose from one (1) to eight (8). From April 2021 to May 2021 the number of alleged staff abuse cases rose from two (2) to eight (8). In June 2021 the number of alleged staff abuse cases was seven (7) and in July 2021 the number was eight (8). The document does not include an analysis of the rates or trends.

2. Review of a document titled, "Mildred Mitchell Bateman Hospital Governing Board Meeting 07/20/21 -- 1:00 PM" revealed review of abuse/neglect rates and trends with a discussion of causes or solutions are not included.

3. An interview was conducted with the Chief Executive Officer (CEO) on 10/26/21 at 5:15 p.m. She/he acknowledged the GB minutes do not reflect that abuse/neglect trends and their possible causes or resolutions were addressed. Not having the tracking/trending report as part of "Governing Board" as a matrix is in part, "...an oversight, but we can certainly add it." She/he stated she/he is not sure there is written documentation of discussion regarding trends of abuse/neglect. Written discussion in part, "...needs to be reduced and documented."

4. An interview was conducted with the Survey Coordinator on 10/27/21 at 8:20 a.m. After reviewing the GB meeting minutes listed above, he/she acknowledged the minutes do not reflect abuse/neglect trends and causes of those trends with resolutions. Quality Assurance/Performance Improvement (QA/PI) information relative to this information would have been included in the minutes. Without analyzing the causes of spikes in alleged abuse cases it is difficult to know what interventions are needed.

Based on clinical record review, video review, document review and interview it was revealed the facility failed to protect and promote a patient's rights to emergency medical care. The facility failed to analyze trends in allegations of abuse and neglect. The facility failed to ensure the grievance policy was followed. These failures place all patients at risk for harm. (See tags A 123, A 144 and A 145).

Based on review of documents and interview it was revealed the facility failed to follow its policy and procedure for grievances and complaints for two (2) out of ten (10) patients (patient #9 and 10). The facility failed to ensure full investigations were done and follow-up letters of resolution were sent.

Findings include:

1. Review of a document titled, "Handling of Patient Complaint/Grievances," revised 10/18/21, revealed in part: "The intent is to address patient complaints and grievances regarding patient care and services in a timely and responsive manner...The patient advocate is responsible for keeping an accurate record of all grievances, of actions taken, and their resolution. The Legal Aid Patient Advocate will notify the patient or patient's representative in writing using the Patient Grievance Form that the grievance has been resolved and what the resolution was within {seven} 7 business days of receiving compliant/grievance. If the grievance will not be resolved or completed within {seven} business days, the Legal Aid Patient Advocate should inform the patient or patient's representative, the CEO (Chief Executive Officer) or the CEO designee in regards to when the investigation will be completed and that the hospital is still working to resolve the grievance..." There is no reference in the document to stopping the grievance process because the complainant was discharged.

2. Review of grievance documentation for patient #9 revealed he/she submitted grievances on 9/19/21 and 9/29/21. There was no evidence the complaints were investigated by the advocate. Final letters of resolution were not sent.

3. Review of grievance documentation for patient #10 revealed he/she submitted a grievance on 9/21/21. There was no evidence the complaint was investigated by the patient advocate. Initial and resolution letters were not sent.

4. Review of a document titled, "Hospital Governing Body {GB} Bylaws" revealed in part: "For this purpose, the Corporate board has delegated to the Governing Body the authority to...oversee performance improvement, utilization review, risk management, and similar matters regarding the provision of quality patient care at the Hospital..."

5. Review of a document titled, "Mildred Mitchell-Bateman Hospital Governing Board Meeting 07/20/21 -- 1:00 PM" revealed review of complaints and grievances, but a report from the grievance committee was not included.

6. An interview was conducted with the CEO on 10/26/21 at 5:15 p.m. She/he acknowledged grievances/complaints are not documented as part of the GB meeting minutes. They discuss them but do not document discussion of how the grievances/complaints were addressed.

7. An interview was conducted with the Survey Coordinator on 10/27/21 at 8:20 a.m. After reviewing the GB meeting minutes listed above, he/she acknowledged the minutes do not reflect that grievances/complaints were addressed. Although he/she did not agree the GB does not support the Quality Assurance/Performance Improvement (QA/PI) efforts in relation to grievances, QA/PI reports and GB responses would have been included in the GB meeting minutes.

8. Patient advocates #1 and #2 were not available for interview.

Based on review of clinical records, video review, document review and interview it was revealed the facility failed to promote and protect patient rights to immediate emergency care for one (1) out of ten (10) patients (patient #1) after she/he was assaulted by a co-patient and suffered facial fractures. This failure to ensure immediate emergency care is provided creates the potential for serious harm, injury or death for all patients.

Findings include:

1. Review of clinical records revealed patient #1 was a fifty-nine (59) year-old with a diagnosis of Chronic Paranoid Schizophrenia. He/she was admitted on 8/18/21. Registered nurse (RN) #2 noted in part, "On 9/9/21 at 11:38 (patient #1) was in the dining area on Unit Two (2) when a (male/female) co-patient walked up to (patient #1) and hit (patient #1) with a closed fist multiple times in the face. (Patient #1) was knocked out between (two) 2 and three (3) minutes. Also observed a large pool of urine around patient." Patient #1 was transferred to Cabell Huntington Hospital where he/she was diagnosed with an orbital fracture (broken bone around the eye), mandibular fracture (broken jaw) and maxillary fracture (broken cheek bone). On 10/8/21 he/she underwent an open reduction and internal fixation of his/her jaw (ORIF--surgery that involves cutting into the body to access the bone and realign it. Then the bone is kept in realignment with hardware such as pins, plates, rods or screws).

2. Review of clinical records revealed patient #2 was a thirty-six (36) year-old with a diagnosis of Borderline Personality Disorder.

3. Videotape was reviewed by the surveyor, the Human Resources Director (HRD) and Quality Assurance/Performance Improvement (QA/PI) on 10/25/21 at 4:10 p.m. Footage was viewed for 9/9/21 on Unit Two (2) with a view of the dayroom from 1:37 p.m. to 1:42:37 p.m. At 1:38:21 patient #2 goes to patient #1 (who is sitting with his head relaxed back against the wall) and punches him/her in the face seven (7) times. He/she then walks away. At 1:38:36 patient #1 is seen tilting to the side. Health service worker (HSW) #4 walks with patient #2 down the patient hall next to the nurse's station, passing the nurse's station door. At 1:38:40 patient #1 falls into the floor. At 1:38:48 a patient (unknown) goes to patient #1 and attempts to lift him under his arms. That patient releases him/her back to the floor and backs away. At 1:39:11 RN #3 goes toward patient #1, then turns back toward the nurse's station. At 1:39:17 RN #2 comes toward the dayroom and crosses paths with RN #3 and goes toward patient #1. At 1:39:24 RN #2 looks toward the nurse's station and RN #4 walks around in the day area. At 1:40:06 RN #2 bends down over patient #1. At 1:40:12 RN #4 brings a white object (towel? sheet?) and moves it to patient #1's head. At this point, RN #2 is the first person to touch patient #1 after he/she was assaulted. At 1:41:18 additional personnel are noted coming around patient #1 (The HRD and QA/PI state this is the code orange team).

4. Review of a document titled, "Code Call Sheet Switchboard" revealed a code orange (medical emergency) and a code 3S (security) were called for Unit Two (2) on 9/9/21 at 1:41 p.m.

5. Review of a document titled, "MMBH SWITCHBOARD OPERATOR LOG" revealed on 9/9/21 at 1:41 p.m. the operator noted code 3S and orange on A2 (Unit Two). Review of the document revealed in part: "woman panicked over phone, said A3 not A2...called it on A3, A3 called back-not their floor-second woman called much more calm and clarified it was A2."

6. An interview was conducted with the HRD on 10/25/21 at the close of the videotape review (5:00 p.m.) He/she stated he/she had watched the videotape several times before. He/she stated he/she had watched it with the Assistant Chief Nursing Executive (ACNE), the Chief Executive Officer (CEO) and maybe with QA/PI.

7. An interview was conducted with the Chief Nursing Director (CNE) on 10/27/21 at 9:10 a.m. He/she stated he/she is not aware of a lot of what happens in the hospital in regards to nursing services. When asked if he/she had viewed the video, he/she responded, "No ma'am. I'm not called to review videos." When asked if anyone was reprimanded or re-educated after the incident or if he/she interviewed the staff, he/she stated, "No. I'm not involved with that aspect ever." He/she is given a report about the number of incidents, when they occur and where they occur. He/she is not given details so he/she can follow-up if needed. "I don't know nothing. They send (the ACNE) to review the videos." When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated no. "In my opinion, five (5) seconds is too long. He/she should have been assessed." He/she never reviews switchboard code sheets to monitor codes. He/she did not know the code orange called for patient #1 on 9/9/21 at 1:40 p.m. was originally called to the wrong unit.

8. An interview was conducted with the Assistant CNE 10/27/21 at 9:45 a.m. He/she stated he/she has only "recently" started getting incident reports sent to him/her. Sometimes he/she gets to review them daily, but sometimes not. QA/PI also gets the reports and deals with that. He/she reviewed the video of patient #1's assault. He/she only knew about the incident and the need to review the tape because the patient advocate alerted him/her. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated, "No, it was too long a length of time."

Based on clinical record review, video review, document review and interview it was revealed the facility neglected to provide immediate emergency medical care to one (1) out of ten (10) patients (patient #1). Patient #1 was assaulted and was not assessed for thirty-five (35) seconds, during which time several nurses were aware of the situation. This failure places all patients at risk for serious harm, injury, impairment or death.

Findings include:

1. Review of clinical records revealed patient #1 was a fifty-nine (59) year-old with a diagnosis of Chronic Paranoid Schizophrenia. He/she was admitted on 8/18/21. Registered nurse (RN) #2 noted in part, "On 9/9/21 at 11:38 (patient #1) was in the dining area on Unit Two (2) when a (male/female) co-patient walked up to (patient #1) and hit (patient #1) with a closed fist multiple times in the face. (Patient #1) was knocked out between (two) 2 and three (3) minutes. Also observed a large pool of urine around patient." Patient #1 was transferred to Cabell Huntington Hospital where he/she was diagnosed with an orbital fracture (broken bone around the eye), mandibular fracture (broken jaw) and maxillary fracture (broken cheek bone). On 10/8/21 he/she underwent an open reduction and internal fixation of his/her jaw (ORIF--surgery that involves cutting into the body to access the bone and realign it. Then the bone is kept in realignment with hardware such as pins, plates, rods or screws).

2. Review of clinical records revealed patient #2 was a thirty-six (36) year-old with a diagnosis of Borderline Personality Disorder.

3. Videotape was reviewed by the surveyor, the Human Resources Director (HRD) and Quality Assurance/Performance Improvement (QA/PI) on 10/25/21 at 4:10 p.m. Footage was viewed for 9/9/21 on Unit Two (2) with a view of the dayroom from 1:37 p.m. to 1:42:37 p.m. At 1:38:21 patient #2 goes to patient #1 (who is sitting with his head relaxed back against the wall) and punches him/her in the face seven (7) times. He/she then walks away. At 1:38:36 patient #1 is seen tilting to the side. Health service worker (HSW) #4 walks with patient #2 down the patient hall next to the nurse's station, passing the nurse's station door. At 1:38:40 patient #1 falls into the floor. At 1:38:48 a patient (unknown) goes to patient #1 and attempts to lift him under his arms. That patient releases him/her back to the floor and backs away. At 1:39:11 RN #3 goes toward patient #1, then turns back toward the nurse's station. At 1:39:17 RN #2 comes toward the dayroom and crosses paths with RN #3 and goes toward patient #1. At 1:39:24 RN #2 looks toward the nurse's station and RN #4 walks around in the day area. At 1:40:06 RN #2 bends down over patient #1. At 1:40:12 RN #4 brings a white object (towel? sheet?) and moves it to patient #1's head. At this point, RN #2 is the first person to touch patient #1 after he/she was assaulted. At 1:41:18 additional personnel are noted coming around patient #1 (The HRD and QA/PI state this is the code orange team).

4. An interview was conducted with RN #3 on 10/26/21 at 4:55 p.m. She/he acknowledged there were three (3) RNs working on Unit Two (2) when the assault occurred.

5. An interview was conducted with the Chief Nursing Executive (CNE) on 10/27/21 at 9:10 a.m. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated no. "In my opinion, five (5) seconds is too long. He/she should have been assessed."

6. An interview was conducted with the Assistant CNE on 10/27/21 at 9:45 a.m. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, she stated, "No, it was too long a length of time."

7. Review of a document titled, "LEGAL AID of West Virginia...Patient: (Patient #1)..Date: September 21, 2021" revealed in part: "Conclusions: Based on the preponderance of all associated information and documentation by Legal Aid Advocate..the incident...is unsubstantiated for abuse/neglect by MMBH staff."

8. Review of a document titled, "MILDRED MITCHELL-BATEMAN HOSPITAL PATIENT GRIEVANCE REVIEW COMMITTEE RESOLUTIONS OF PGRC INVESTIGATION/REVIEW" revealed in part: "(Patient #1)....BRIEF SUMMARY OF ISSUE: co pt punched pt in face several times. RESOLUTION Staff attended to pt after attack. Unsubstantiated for abuse/neglect by MB staff. REVIEW OF VIDEO co pt (Patient #2) approached (Patient #1) while (Patient #1) in the face several times, staff intervened promptly."

Based on document review and interview it was revealed Quality Assurance/Performance Improvement (QA/PI) failed to analyze trends in alleged abuse and neglect so follow-up could be done. This failure creates the potential causes of abuse and neglect are not identified so protective action could be taken for the patients. This places all patients at risk for harm.

Findings include:

1. Review of a document titled, "QAPI Committee Agenda-September 28, 2021 (rescheduled from 9/23/21 Reporting Period is for AUGUST 2021" revealed it includes rates of alleged staff abuse broken down by month from January 2021 through August 2021. From January 2021 to February 2021 the number of alleged staff abuse cases rose from one (1) to eight (8). From April 2021 to May 2021 the number of alleged staff abuse cases rose from two (2) to eight (8). In June 2021 the number of alleged staff abuse cases was seven (7) and in July 2021 the number was eight (8). The document does not include an analysis of the rates or trends.

2. Review of a document titled, "Mildred Mitchell Bateman Hospital Governing Board Meeting 07/20/21 -- 1:00 PM" revealed review of abuse/neglect rates and trends with a discussion of causes or solutions are not included.

3. An interview was conducted with the Chief Executive Officer (CEO) on 10/26/21 at 5:15 p.m. She/he acknowledged the governing body (GB) minutes do not reflect that abuse/neglect trends and their possible causes or resolutions were addressed. Not having the tracking/trending report as part of "Governing Board" as a matrix is in part, "...an oversight. But we can certainly add it." She/he stated she/he is not sure there is written documentation of discussion regarding trends of abuse/neglect. Written discussion in part, "...needs to be reduced and documented."

4. An interview was conducted with the Survey Coordinator on 10/27/21 at 8:20 a.m. After reviewing the GB meeting minutes listed above, he/she acknowledged the minutes do not reflect abuse/neglect trends and causes of those trends with resolutions. QA/PI information relative to this information would have been included in the minutes. Without analyzing the causes of spikes in alleged abuse cases it is difficult to know what interventions are needed.

Based on clinical record review, video review and interview it was revealed the Director of Nursing failed to provide organized nursing services to one (1) out of ten (10) patients (patient #1). This failure resulted in delay of care which could have resulted in permanent harm. Delays in care place all patients at risk for harm, injury, impairment or death. (See tags A 386 and A 395).

Based on review of clinical records, video review, document review and interview it was revealed the Chief Nursing Officer failed to ensure he/she supervised all aspects of nursing care in the facility by not ensuring she/he was aware of a sentinel event which resulted in patient injury requiring acute medical care for one (1) out of ten (10) patients (patient #10). This failure to ensure nursing care is under his/her supervision creates the potential care is not given according to policy and procedure and industry standards, resulting in harm for all patients.

Findings include:

1. Review of clinical records revealed patient #1 was a fifty-nine (59) year-old with a diagnosis of Chronic Paranoid Schizophrenia. He/she was admitted on 8/18/21. Registered nurse (RN) #2 noted in part, "On 9/9/21 at 11:38 (patient #1) was in the dining area on Unit Two (2) when a (male/female) co-patient walked up to (patient #1) and hit (patient #1) with a closed fist multiple times in the face. (Patient #1) was knocked out between (two) 2 and three (3) minutes. Also observed a large pool of urine around patient." Patient #1 was transferred to Cabell Huntington Hospital where he/she was diagnosed with an orbital fracture (broken bone around the eye), mandibular fracture (broken jaw) and maxillary fracture (broken cheek bone). On 10/8/21 he/she underwent an open reduction and internal fixation of his/her jaw (ORIF--surgery that involves cutting into the body to access the bone and realign it. Then the bone is kept in realignment with hardware such as pins, plates, rods, or screws).

2. Review of clinical records revealed patient #2 was a thirty-six (36) year-old with a diagnosis of Borderline Personality Disorder.

3. Videotape was reviewed by the surveyor, the Human Resources Director (HRD) and Quality Assurance/Performance Improvement (QA/PI) on 10/25/21 at 4:10 p.m. Footage was viewed for 9/9/21 on Unit Two (2) with a view of the dayroom from 1:37 p.m. to 1:42:37 p.m. At 1:38:21 patient #2 goes to patient #1 (who is sitting with his head relaxed back against the wall) and punches him/her in the face seven (7) times. He/she then walks away. At 1:38:36 patient #1 is seen tilting to the side. Health service worker (HSW) #4 walks with patient #2 down the patient hall next to the nurse's station, passing the nurse's station door. At 1:38:40 patient #1 falls into the floor. At 1:38:48 a patient (unknown) goes to patient #1 and attempts to lift him under his arms. That patient releases him/her back to the floor and backs away. At 1:39:11 RN #3 goes toward patient #1, then turns back toward the nurse's station. At 1:39:17 RN #2 comes toward the dayroom and crosses paths with RN #3 and goes toward patient #1. At 1:39:24 RN #2 looks toward the nurse's station and RN #4 walks around in the day area. At 1:40:06 RN #2 bends down over patient #1. At 1:40:12 RN #4 brings a white object (towel? sheet?) and moves it to patient #1's head. At this point, RN #2 is the first person to touch patient #1 after he/she was assaulted. At 1:41:18 additional personnel are noted coming around patient #1 (The HRD and QA/PI state this is the code orange team).

4. Review of a document titled, "Code Call Sheet Switchboard" revealed a code orange (medical emergency) and a code 3S (security) were called for Unit Two (2) on 9/9/21 at 1:41 p.m.

5. Review of a document titled, "MMBH SWITCHBOARD OPERATOR LOG" revealed on 9/9/21 at 1:41 p.m. the operator noted code 3S and orange on A2 (Unit Two). Review of the document revealed in part: "woman panicked over phone, said A3 not A2...called it on A3, A3 called back-not their floor-second woman called much more calm and clarified it was A2."

6. An interview was conducted with the HRD on 10/25/21 at the close of the videotape review (5:00 p.m.) He/she stated he/she had watched the videotape several times before. He/she stated he/she had watched it with the Assistant CNE, the Chief Executive Officer (CEO) and maybe with QA/PI.

7. An interview was conducted with the Chief Nursing Director (CND) on 10/27/21 at 9:10 a.m. He/she stated he/she is not aware of a lot of what happens in the hospital in regards to nursing services. When asked if he/she had viewed the video, he/she responded, "No ma'am. I'm not called to review videos." When asked if anyone was reprimanded or re-educated after the incident or if he/she interviewed the staff, he/she stated, "No. I'm not involved with that aspect ever." He/she is given a report about the number of incidents, when they occur and where they occur. He/she is not given details so he/she can follow-up if needed. "I don't know nothing. They send (the ACNE) to review the videos." When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated no. "In my opinion, five (5) seconds is too long. He/she should have been assessed." He/she never reviews switchboard code sheets to monitor codes. He/she did not know the code orange called for patient #1 on 9/9/21 at 1:40 p.m. was originally called to the wrong unit.

8. An interview was conducted with the Assistant CNE 10/27/21 at 9:45 a.m. He/she stated he/she has only "recently" started getting incident reports sent to him/her. Sometimes he/she gets to review them daily, but sometimes not. QA/PI also gets the reports and deals with that. He/she reviewed the video of patient #1's assault. He/she only knew about the incident and the need to review the tape because the patient advocate alerted him/her. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated, "No, it was too long a length of time."

Based on video review, interview and document review it was revealed the Director of Nursing failed to ensure registered nurses (RNs) provide emergency medical care to patients in one (1) out of ten (10) patients. RNs delayed providing emergency assistance to a patient who had been assaulted. Delay in care during a medical emergency creates the potential for serious injury, harm, impairment, or death to all patients.

Findings include:

1. Review of clinical records revealed patient #1 was a fifty-nine (59) year-old with a diagnosis of Chronic Paranoid Schizophrenia. He/she was admitted on 8/18/21. RN #2 noted in part, "On 9/9/21 at 11:38 (patient #1) was in the dining area on Unit Two (2) when a (male/female) co-patient walked up to (patient #1) and hit (patient #1) with a closed fist multiple times in the face. (Patient #1) was knocked out between (two) 2 and three (3) minutes. Also observed a large pool of urine around patient." Patient #1 was transferred to Cabell Huntington Hospital where he/she was diagnosed with an orbital fracture (broken bone around the eye), mandibular fracture (broken jaw) and maxillary fracture (broken cheek bone). On 10/8/21 he/she underwent an open reduction and internal fixation of his/her jaw (ORIF--surgery that involves cutting into the body to access the bone and realign it. Then the bone is kept in realignment with hardware such as pins, plates, rods, or screws).

2. Review of clinical records revealed patient #2 was a thirty-six (36) year-old with a diagnosis of Borderline Personality Disorder.

3. Videotape was reviewed by the surveyor, the Human Resources Director (HRD) and Quality Assurance/Performance Improvement (QA/PI) on 10/25/21 at 4:10 p.m. Footage was viewed for 9/9/21 on Unit Two (2) with a view of the dayroom from 1:37 p.m. to 1:42:37 p.m. At 1:38:21 patient #2 goes to patient #1 (who is sitting with his head relaxed back against the wall) and punches him/her in the face seven (7) times. He/she then walks away. At 1:38:36 patient #1 is seen tilting to the side. Health service worker (HSW) #4 walks with patient #2 down the patient hall next to the nurse's station, passing the nurse's station door. At 1:38:40 patient #1 falls into the floor. At 1:38:48 a patient (unknown) goes to patient #1 and attempts to lift him under his arms. That patient releases him/her back to the floor and backs away. At 1:39:11 RN #3 goes toward patient #1, then turns back toward the nurse's station. At 1:39:17 RN #2 comes toward the dayroom and crosses paths with RN #3 and goes toward patient #1. At 1:39:24 RN #2 looks toward the nurse's station and RN #4 walks around in the day area. At 1:40:06 RN #2 bends down over patient #1. At 1:40:12 RN #4 brings a white object (towel? sheet?) and moves it to patient #1's head. At this point, RN #2 is the first person to touch patient #1 after he/she was assaulted. At 1:41:18 additional personnel are noted coming around patient #1 (The HRD and QA/PI state this is the code orange team).

4. An interview was conducted with RN #3 on 10/26/21 at 4:55 p.m. He acknowledged there were three (3) RNs working on Unit Two (2) when the assault occurred.

5. An interview was conducted with the Chief Nursing Executive (CNE) on 10/27/21 at 9:10 a.m. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, he/she stated no. "In my opinion, five (5) seconds is too long. He/she should have been assessed."

6. An interview was conducted with the Assistant CNE on 10/27/21 at 9:45 a.m. When asked if thirty-five (35) seconds was an acceptable amount of time between the assault and the first time a staff member touched patient #1 to assess him/her, she stated, "No, it was too long a length of time."

7. Review of a document titled, "LEGAL AID of West Virginia...Patient: (Patient #1). Date: September 21, 2021" revealed in part: "Conclusions: Based on the preponderance of all associated information and documentation by Legal Aid Advocate. The incident...is unsubstantiated for abuse/neglect by MMBH staff."

8. Review of a document titled, "MILDRED MITCHELL-BATEMAN HOSPITAL PATIENT GRIEVANCE REVIEW COMMITTEE RESOLUTIONS OF PGRC INVESTIGATION/REVIEW" revealed in part: "(Patient #1) .... BRIEF SUMMARY OF ISSUE: co pt. punched pt. in face several times. RESOLUTION Staff attended to pt. after attack. Unsubstantiated for abuse/neglect by MB staff. REVIEW OF VIDEO co pt. (Patient #2) approached (Patient #1) while (Patient #1) in the face several times, staff intervened promptly."