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West Virginia Licensure Rule CSR 64-12-5

5.1.b.1 The following documents are adopted as construction, equipment, physical facility, and related procedural standards for all existing hospitals, all new construction and any additions, alterations, renovations, or conversions of existing buildings: The relevant sections of the 2001 edition of The Guidelines for Design and Construction of Hospitals and Health Care Facilities as recognized by the American Institute of Architects Academy of Architecture for Health with assistance from the United States Department of Health and Human Resources shall be used as planning standards;

5.4.a Additions and renovations or alterations of any hospital which are begun after the effective date of this rule shall comply with the General and Psychiatric Hospital sections, as applicable, of the latest edition of Guidelines for Design and Construction of Hospitals and Health Care Facilities.

5.4.d The hospital shall submit to the Director for review, complete construction drawings and specifications for any hospital construction project which alters a floor plan, impacts life safety or requires approval under W. Va. Code ?16-2D-1 et seq. prior to beginning work on the project. An architect and/or engineer registered to practice in West Virginia, shall prepare and sign the drawings and specifications including architectural, life safety, structural, mechanical and electrical drawings and specifications. Minor renovations which alter floor plans may not require the services of an architect and a full set of drawings. However, an actual as built drawing is required for the specific area to be renovated. The approval of minor renovations shall be determined by the Secretary.

This Standard is not Met as evidenced by:

Based on observation and staff interview it was determined the hospital failed to met all standards for licensing established by The Office of Health Facility Licensure and Certification for the state of West Virginia and in accordance with West Virginia Licensure Rule CSR 64-12-5, 5.1.b.1, 5.4.a, and 5.4.d for alteration and conversion to the hospital. This failure has the potential to adversely affect the safety of all patients housed in the 1 East conversion area.

Findings include:

1. An interview with the Director of Nursing/Risk Manager on 01/25/12 at approximately 10:00 a.m. was conducted. This interview revealed that approximately four (4) months back from today's date (01/25/12), the hospital moved the forensic patients from 3 East to 1 East. This interview also revealed that the 1 East area was last used for patient care in the late 1990's and was used for an adolescent out-patient day program. This area was then used as a billing office before it was converted to an inpatient forensic unit. This interview also indicated that 1 East is currently being used to house forensic male inpatients.

2. During a tour of the 1 East area with the Director of Nursing on 01/25/12 at approximately 10:30 a.m. the following design and safety concerns were observed:

a. There were five (5) semi-private patient rooms with a total of ten (10) inpatient beds. The census at the time of the observations was ten (10) inpatients.
b. There were a total of three (3) toilet rooms for patient use (accessible only from the corridor) for use by the ten (10) patients. There were no toilets accessible from inside each patient room.
c. There was one (1) central bath equipped with only one (1) shower stall for use by the ten (10) patients.
d. The corridor, television room, day room and staff break/vending machine room had lay-in-ceiling tiles that were not secured (unclipped).
e. The corridor, clean linen supply closet, staff break/vending machine room, television room and day room had pendant-type sprinkler heads (which were not tamper resistant).
f. There were self-closing devices on the tops of corridor doors (washer/dryer room, room 121, room 125, and double doors across corridor).
g. There were regular type door hinges (not approved slant type) on the following corridor doors: clean linen supply closet, laundry room, day room, and double doors across corridor.
h. There were lever-type or ball-knob type door handles on the following corridor doors: room 120, clean linen supply closet, day room, and housekeeping closet.
i. Water service handles and faucet for hand sinks and shower water service handle were not the approved type in following rooms: rooms 120, 121, and 127.
j. The dryer vent in laundry room was vented into a container of water and not vented to the outside of the building as required.

3. An interview with the Director of Nursing/Risk Manager on 01/25/12 at approximately 11:00 a.m., revealed there was no documentation available to indicate that the hospital conversion plan for 1 East was submitted to the Office of Health Facility Licensure and Certification for approval. Therefore, the conversion of the 1 East area for the housing of forensic patients has not been approved by the authority having jurisdiction (Office of Health Facility Licensure and Certification). The renovations to the 1 East unit do not meet the minimum construction standards of the 2001 edition of The Guidelines for Design and Construction of Hospitals and Health Care Facilities as recognized by the American Institute of Architects Academy of Architecture for Health with assistance from the United States Department of Health and Human Resources.

Based on observation and staff interview during a complaint investigation conducted on 01/25/12 it was determined the hospital failed to provide/maintain the required special design consideration for a safe environment and to prevent potential patient injury or suicide (due to the observation of a large number of looping devices) on eight (8) of eight (8) patient care units. Therefore, this Condition is not met. Refer to deficiencies identified as A022 and A722.

Based on observation and staff interview it was determined the hospital failed to maintain the required special design consideration for a safe environment by failing to remove all potential looping devices in all patient care units. This has the potential to create a situation in which patients may be able to harm themselves in an unsafe environment.

Findings include:

1. On 01/25/12 from 10:30 a.m. to 3:30 p.m., a tour of the hospital behavioral health units was conducted. At this time, the following design requirements of AIA guidelines for Design and Construction of Health Care Facilities in reference to behavioral/psychiatric units were observed not to be met in the following patient units:

a. Pendant type sprinkler heads (not tamper-resistant type).
I. 1 East (corridor, television room, day room, and staff break/vending room).

b. Lay-in-ceiling tiles (not secured).
I. 1 East (corridor, television room, day room, and staff break/vending room).

c. Water service handles for hand sinks/bath tubs/showers (not approved type).
I. 1 East (rooms 120, 121, and 127).
II. 2 North (rooms 241, 242, 243, 244, 245, 246, 254, 255, 256, and 257).
III. 2 East (rooms 240, 248, 252, 253 and central bath hose type shower head and open grab bar).
IV. 2 West (rooms 208, 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219 and 220).
V. 3 North (rooms 351A, 351B, 352A, 353, 354, 355B and 356A).
VI. 3 West (rooms 315A, 315B, 317A, 318B, 320B, 321A, girls bathroom tub and shower).
VII. 4 West (room 401, common men bath tub, and community bathroom).
VIII. 5 West (rooms 502, 503, 504, 508, 509, 510, 511, 512, 513, 514, 515, 517, 518, 519, 520, 521, 522, 524, and 2 community shower rooms).
IX. 5 West (rooms 502, 503, 504, 505, 508, 509,510, 511, 512, 513, 514, 515, 516, 517, 518, 519, 520, and 521).

d. Lever or ball-type door handles in corridors.
I. 1 East (clean linen closet, staff break/vending room, day room, housekeeping room, and fire door to stairwell).
II. 2 North (laundry room and fire exit door).
III. 2 East (medication room, storage room, and fire exit door (panic bar).
IV. 2 West (room 208, linen closet, day room, office, stairwell fire door, and classroom).
V. 3 North (school room, recreation therapist office, exercise room, social worker office, therapy office, day room, staff break room, medication room, staff kitchen, and exit door).
VI. 3 West (therapy office, storage closet, day room, laundry room, back hall exit door, and clean linen storage).
VII. 4 West (room 401 closet, consult rooms, clean linen, room 423 and 407).

e. Regular type door hinges (not approved slant type).
I. 1 East (laundry room, clean linen closet, and double doors across corridor).
II. 2 North (all corridor doors).
III. 2 East (all corridor doors).
IV. 2 West (all corridor doors).
V. 3 North (rooms 350, 351A, 353, 354, 355A, and 356A).

f. Top mounted self-closing devices on corridor doors.
I. 1 East (laundry room, room 125, 127, and double doors across corridor.
II. 2 North (activities office and supply room).
III. 4 West (smoke barrier doors and room 407).
IV. 5 West (smoke barrier doors).

g. Pad locks on patient lockers/furniture.
I. 2 North (rooms 241, 242, 243, 244, 245, 246, 254, 255, 256, and 257).
II. 2 East (rooms 240, 248, 252, and 253),
III. 2 West (rooms 209, 210, 211, 212, 213, 214, 215, 216, 217, 218, 219, 220, and classroom).
IV. 3 North (rooms 351A and 352A).
V. 3 West (rooms 302, 303A, 304B, 309A, 310A, 311A, 312A, 313B, 314, 319B, 321B and 322).
VI. 4 West (rooms 401, 402, 403, 404, and 409).

h. Open type handles on furniture.
I. 2 East (rooms 241, 242, 243, 244, 246, 248, 252 and fire extinguisher cabinet open type handle).
II. 2 West (fire extinguisher cabinet open type handle).

These conditions found on the patient care units are not giving the required special design consideration to prevent potential patient injury or suicide.

2. Interviews with the Director of Nursing, Associate Director of Nursing, and Director of Quality Assurance during the tour of the patient care units on 01/25/12 during the time frame of 10:30 a.m. and 3:30 p.m. confirmed the aforementioned findings found on the patient care units.