HospitalInspections.org

Based on observation and interview it was determined the facility failed to ensure the patient has physical privacy in two (2) of nine (9) rooms toured (rooms #304 and 312). This failure has the potential to deny the patient his/her rights of physical privacy during personal hygiene activities, during medical/nursing treatments and when requested as appropriate.

Findings include:

The Chief Executive Officer (CEO) stated the hospital has been approved for one hundred ten (110) beds. He stated the census was one hundred twenty-nine (129) on 8/22/16 at 10:40 a.m.

A tour was conducted on 8/22/16 at 11:05 a.m. of Unit A3. Observation revealed two (2) of the nine (9) rooms toured on the unit had "C" beds placed in rooms 304 and 312. The beds are plastic beds that are brought up to the unit for patients when the unit is over bed capacity. The personal privacy could not be ensured for the patients when three (3) patients are sleeping in one (1) room. The nursing supervisor was present during the observations and concurred with the findings.

Based on observation and staff interview it was determined the hospital failed to ensure care is provided in a safe setting for nine (9) of nine (9) rooms toured that were not maintained in a safe and sanitary manner (rooms #301, 302, 303, 304, 305, 310, 311, 312, and 313). This failure creates the potential for adverse health issues for all patients.

Findings include:

1. A tour was conducted on 8/22/16 at 11:05 a.m. of Unit A3. Nine (9) of nine (9) toured rooms, 301, 302, 303, 304, 305, 310, 311, 312, and 313 on the unit revealed mold on the shower curtain and three (3) of nine (9) rooms, 305, 312 and 313 revealed mold on the bathroom ceiling. The nursing supervisor was present during the observations and concurred with the findings.

2. An interview was conducted on 8/22/16 at 3:00 p.m. with the Chief Executive Officer. He stated in part..."There had been a ventilation issue in building three (3)."

3. An interview was conducted on 8/24/16 at 9:31 a.m. with the Building Grounds Manager. He reported the ventilation system in building three (3) was old and not working and he had replaced one (1) exhaust fan in May and a second in July of this year.

Based on observation and staff interview it was determined the facility failed to maintain the physical condition of the showers of nine (9) of nine (9) toured rooms on unit A3. (rooms #301, 302, 303, 304, 305, 310, 311, 312, and 313). This failure has the potential to have serious adverse effects on patients' health status.

Findings include:

1. A tour was conducted on 8/22/16 at 11:05 a.m. of unit A3. A total of nine (9) of fifteen (15) rooms were toured on the unit, 301, 302, 303, 304, 305, 310, 311, 312, and 313. All nine (9) rooms revealed mold on the shower curtains and three (3) of the rooms, 305, 312 and 313 revealed mold on the bathroom ceiling. The nursing supervisor was present and concurred with the findings.

2. An interview was conducted on 8/22/16 at 3:00 p.m. with the Chief Executive Officer. He stated in part... "There had been a ventilation issue in building three (3)."

3. An interview was conducted on 8/24/16 at 9:31 a.m. with the Building Grounds Manager. He reported the ventilation system in building three (3) was old and not working and he had replaced one (1) exhaust fan in May and a second one in July of this year.

Based on observation, record review and staff interview, it was determined the hospital failed to maintain adequate facilities for its services. This has the potential to adversely affect the privacy and safety of all hospital patients.

Findings include:

1. The hospital has facilities to accommodate one hundred ten (110) patients. Census records on August 24, 2016 revealed one hundred and twenty nine (129) patients. When exceeding the design of one hundred and ten (110) beds the patients are placed in surroundings where confidentiality and safe conditions cannot be provided.

2. When the hospital exceeds the one hundred and ten (110) bed capacity, a third bed is placed in patient bed rooms.

3. During a tour of the hospital on 08/24/16 the following rooms 214, 308A, 308B, 311B, 312A, 312C, 408 B, 409A, 413A 402 A, 403A and 407B was observed to house three (3) patients.

4. During an interview with the Chief Executive Officer and Assistant Chief Executive Officer on 08/24/16 at approximately 12:35 p.m., it was revealed that they were aware of over bedding.

5. Title 64: West Virginia Administrative Rules, Department of Health and Human Resources
Series 59: Behavioral Health Patients Rights Rule 1995
64-59-2 Application and Enforcement
2.1 Application - This rule applies to State - operated behavioral health facilities.
15.2.3 No person shall be housed in a bedroom with more than one (1) other person. Sleeping areas shall be assigned based on the client's need for group support, privacy and independence.
15.2.4 Each bedroom shall provide a minimum of one hundred (100) square feet per client, excluding closets.
15.2.5 All bedrooms shall have outside windows, be above ground level, and provide adequate space for client privacy.

Based on observation and staff interview it was determined the Chief Executive Officer failed to implement successful action plans to correct facility maintenance issues to ensure care is provided in a sanitary environment for nine (9) of nine (9) toured rooms (rooms #301, 302, 303, 304, 305, 310, 311, 312, and 313). This failure creates the potential for adverse health issues for all patients.

Findings include:

1. A tour was conducted on 8/22/16 at 11:05 a.m. of Unit A3. Nine (9) of nine (9) toured rooms, 301, 302, 303, 304, 305, 310, 311, 312, and 313 on the unit revealed mold on the shower curtain and three (3) of nine (9) rooms, 305, 312 and 313 revealed mold on the bathroom ceiling. The nursing supervisor was present during the observations and concurred with the findings.

2. An interview was conducted on 8/22/16 at 3:00 p.m. with the Chief Executive Officer. He stated in part..."There had been a ventilation issue in building three (3)."

3. An interview was conducted on 8/24/16 at 9:31 a.m. with the Building Grounds Manager. He reported the ventilation system in building three (3) was old and not working and he had replaced one (1) exhaust fan in May and a second in July of this year.