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Based on observation, interview and document review it was revealed the facility failed to ensure staff and patients were kept safe. Staff failed to monitor patients and a staff member was allowed to return to work before a full investigation was completed into an allegation against him/her of verbal abuse. This failure creates the potential for neglect and abuse to patients and potential staff could be seriously injured by an unmonitored patient.

Findings include:

1. On 8/17/21 at approximately 10:40 a.m. on unit G-1, the Licensed Practical Nurse (LPN) was noted briskly walking the hallways checking doors and occasionally sticking his/her head into patient rooms. The G-1 Nurse Manager (NM) saw this occurring and acknowledged it appeared he/she was doing the rounds briskly and not staying long in the patient rooms. Registered Nurse (RN) #1 stated most patients were up at that time of day and rounds could be conducted briskly. The NM accompanied the nurse surveyors to three (3) of the patient rooms the LPN had briskly checked to determine if these patients were in the rooms and awake. Each room had two (2) patients. All six (6) patients were in their beds. All but one (1) had their eyes closed. One (1) had the blanket over his/her head. The NM concurred the LPN had not been in the rooms long enough to see the patients inhale and exhale three (3) times.

2. On 8/17/21 at approximately 12:40 p.m. patients were observed leaving the unit through two (2) locked doors and entering a cafeteria. The NM stated the cafeteria was considered an "off-unit" location. The surveyors questioned the NM how many patients were left on the unit who needed to be observed. The NM stated he/she did not know and asked the staff, who also did not know. Health service worker (HSW) #1 did a check of the unit and stated five (5) patients were left on the unit.

3. Review of a document titled, "Reporting and Investigating Verbal, Physical and Sexual Abuse of Patients and Neglect," effective 10/11/18, revealed in part: "The patient has the right to be free from all forms of abuse. It is the responsibility of all staff to ensure the protection of all patients from verbal, physical, and sexual abuse, exploitation and neglect by identifying and reporting patient abuse... Neglect is any negligent, reckless, or intentional failure to meet the needs of a patient or applicable statutory or regulatory requirements."

4. Review of a document titled, "Nursing Patient Safety Rounds," effective 2/16/21, revealed in part: "The hospital will ensure a safe and therapeutic environment through the implementation of scheduled patient safety checks...The Nurse Manager/Designee is responsible for assigning direct care staff to make unit rounds in order to account for all patient's whereabouts and ensure a safe environment...A Patient Safety Location Log will be placed in Patient Safety Check Sheet Binder to document the patient leaving the unit and returning to the unit...Sleeping patients MUST be observed: watching for THREE (3) breath exchanges {chest rising and falling}..."

5. Review of a document titled, "Key and Card Access," effective 4/8/19, revealed in part: "Key and keycard holder shall not "prop" doors open or leave them unlocked."

6. Review of a document titled, "Contraband and Search," effective 5/21/19, revealed in part: "The purpose of this policy is to enhance safety by identifying and preventing dangerous objects {contraband} from entering into the therapeutic environment...patients, staff and visitors also have a right to a safe and therapeutic environment which under certain circumstances necessitates taking steps to ensure patients are not in possession of items that may present a hazard to personal safety.

7. Video review and interview revealed the nurse's station was not being kept locked to prevent access to objects the patient could potentially use to cause self-harm or harm to staff as per policy and procedure.

8. On 8/18/21 at approximately 10:40 a.m. a video was watched by the Information Systems Specialist, the Chief Nursing Officer and the NM, along with the surveyors. The video was of the nurse's station on 7/4/21 spanning the time period between 9:31:32 a.m. and 9:41:36 a.m. During the video the nurse's station doors were noted left standing open while nursing staff were in and out of the station. At one point, a door to the nurse's station was left open, without staff present, for approximately one (1) minute. During the time the door was open, one (1) patient (patient #8) walked slightly inside the open doorway. Other patients were around the open doorway at various times (patients #7 and 9).

9. An interview was conducted on 8/17/21 at 1:05 p.m. with the NM. He/she concurred the hallwalks were not being done according to policy and procedure to ensure patient safety. He/she concurred the patients were not being tracked during meals to ensure their location was known so their well-being could be monitored. He/she concurred these were unsafe practices.

10. On 8/18/21 at approximately 11:00 a.m. the Chief Nursing Officer (CNO) and NM acknowledged the doors to the nurse's room were left open and at one point, over a one (1) minute period, the nurse's station was unlocked and unattended. They concurred this was against policy and procedure and created an unsafe environment for the patients.

Based on record review, document review and interview it was revealed the facility failed to ensure a Registered Nurse (RN) who allegedly verbally abused a patient (patient #2) was removed from duty when the allegation was made and kept from returning to duty until the advocate's investigation was complete. This failure creates the potential staff with alleged abuse against them are allowed to return to work and if the allegation was substantiated, place patients at risk for further abuse.

Findings include:

1. A review of patient #2's clinical record revealed he/she was a thirty-eight (38) year-old with a diagnosis of schizoaffective disorder. On 7/3/21 at 6:30 p.m. he/she accused the RN of verbally abusing him/her. He went on to tell other patients that he/she felt the RN called him names. The RN worked the remainder of that shift and a shift the following date (7/4/21). He/she also worked 7/9/21 through 7/11/21.

2. A review of key card swipes (indicating when RN #1 was in the building) revealed he/she was in the building 7/3/21, 7/4/21, 7/9/21, 7/10/21 and 7/11/21.

3. A review of a document titled, "Adult Protective Services Mandatory Reporting Form" revealed a report of verbal abuse naming the RN as the alleged perpetrator was made on 7/6/21. The report notes a behavior note in the patient's clinical record showed he/she initially made the complaint on 7/3/21.

4. A review of a document titled, "LEGAL AID OF WEST VIRGINIA" Dated 7/13/21 revealed it was a report sent from the Behavioral Health Advocate (BHA) to the Chief Executive Officer (CEO) regarding patient #2's allegations made on 7/3/21. The document notes the BHA interviewed three (3) staff members and patient #2. The final interview was with patient #2 and occurred on 7/12/21 at 2:10 p.m. The conclusion was located at the end of the document, after the interview with patient #2.

5. An interview was conducted on 8/16/21 at 12:25 p.m. with the Chief Nursing Officer (CNO). She stated the procedure followed when a staff member has allegedly abused a patient is to immediately pull them off the unit, suspend him/her pending the investigation, pull his/her badge and keys and escort them out of the building.

6. An interview was conducted on 8/16/21 at 4:00 p.m. with the Chief Executive Officer (CEO). He acknowledged the RN was returned to work before the conclusion of the BHA's investigation. He stated the BHA talked to him during her investigation and told him it would probably be unsubstantiated. The surveyor asked him if he was supposed to wait on the BHA's conclusion and findings of the investigation before returning a staff remember to duty after an allegation of abuse. He stated in part, "I believe our policy says I have latitude" on whether a staff member can be allowed to return to work before the advocate's investigation has been completed. He concurred he allowed the RN to return to work before the advocate made her final conclusion on the investigation. He said he went off of what she told him on the phone prior to RN being put back to work. He stated the BHA "thought" the allegation was going to wind up being unsubstantiated.

7. An interview was conducted on 8/16/21 at 3:00 p.m. with the BHA. She stated she interviewed patient #2 on 7/12/21. She denied interviewing him/her at any other time. She stated, "I always try to speak to the patient because there is always a chance something was said and only the patient heard it." She reached her conclusion after her interview with patient #2. She sent the report concluding the allegation was unsubstantiated to the CEO on 7/13/21, but it is possible she told him her conclusion on 7/12/21 by phone. Although the hospital does it's own investigation, the advocate's investigation is to be considered, "part and parcel" when making the decision whether or not to substantiate the allegation. This means the conclusion of their investigation is to be part of the final decision of whether the staff member will be allowed to return to duty.

Based on observation, interview and document review it was revealed the facility failed to ensure supervisory nursing staff kept patients safe. Nursing supervisory staff failed to monitor patient location and activity through supervising patient observation rounds. Nursing supervisory staff also failed to ensure the nurses ' station was kept secure against entry by patients, who would then have access to contraband. These failures create the potential for harm to staff and patients.

Findings include:

1. On 8/17/21 at approximately 10:40 a.m. on unit G-1, the Licensed Practical Nurse (LPN) was noted briskly walking the hallways checking doors and occasionally sticking her head into patient rooms. The G-1 Nurse Manager (NM) saw this occurring and acknowledged it appeared she was doing the rounds briskly and not staying long in the patient rooms. Registered Nurse (RN) #1 stated most patients were up at that time of day and rounds could be conducted briskly. The NM accompanied the nurse surveyors to three (3) of the patient rooms the LPN had briskly checked to determine if these patients were in the rooms and awake. Each room had two (2) patients. All six (6) patients were in their beds. All but one had their eyes closed. One had the blanket over his/her head. The NM concurred the LPN had not been in the rooms long enough to see the patients inhale and exhale three (3) times.

2. On 8/17/21 at approximately 12:40 p.m. patients were observed leaving the unit through two (2) locked doors and entering a cafeteria. The NM stated the cafeteria was considered an "off-unit" location. The surveyors questioned the NM how many patients were left on the unit who needed to be observed. The NM stated he did not know and asked the staff, who also did not know. Health service worker (HSW) #1 did a check of the unit and stated five (5) patients were left on the unit.

3. Review of a document titled, "Reporting and investigating Verbal, Physical and Sexual Abuse of Patients and Neglect" effective 10/11/18 revealed in part, "The patient has the right to be free from all forms of abuse. It is the responsibility of all staff to ensure the protection of all patients from verbal, physical, and sexual abuse, exploitation and neglect by identifying and reporting patient abuse....Neglect is any negligent, reckless, or intentional failure to meet the needs of a patient or applicable statutory or regulatory requirements."

4. Review of a document titled, "Nursing Patient Safety Rounds" effective 2/16/21 revealed in part, "The hospital will ensure a safe and therapeutic environment through the implementation of scheduled patient safety checks...The Nurse Manager/Designee is responsible for assigning direct care staff to make unit rounds in order to account for all patient's whereabouts and ensure a safe environment...A Patient Safety Location Log will be placed in Patient Safety Check Sheet Binder to document the patient leaving the unit and returning to the unit...Sleeping patients MUST be observed: watching for THREE (3) breath exchanges {chest rising and falling}..."

5. Review of a document titled, "Key and Card Access" effective 4/8/19 revealed in part, "Key and keycard holder shall not "prop" doors open or leave them unlocked."

6. Review of a document titled, "Contraband and Search" effective 5/21/19 revealed in part, "The purpose of this policy is to enhance safety by identifying and preventing dangerous objects {contraband} from entering into the therapeutic environment...patients, staff and visitors also have a right to a safe and therapeutic environment which under certain circumstances necessitates taking steps to ensure patients are not in possession of items that may present a hazard to personal safety..)

7. Video review and interview revealed the nurse's station was not being kept locked to prevent access to objects the patient could potentially use to cause self-harm or harm to staff as per policy and procedure:

8. On 8//18/21 at approximately 10:40 a.m. a video was watched by the Information Systems Specialist, the Chief Nursing Officer and the NM, along with the surveyors. The video was of the nurses' station on 7/4/21 spanning the time period between 9:31:32 a.m. and 9:41:36 a.m. During the video the nurses station doors were noted left standing open while nursing staff were in and out of the station. At one point, a door to the nurses' station was left open, without staff present, for approximately one (1) minute. During the time the door was open, one patient (Patient #8) walked slightly inside the open doorway. Other patients were around the open doorway at various times (Patients #7 and #9).

9. An interview was conducted on 8/17/21 at 1:05 p.m. with the NM. He concurred the hallwalks were not being done according to policy and procedure to ensure patient safety. He concurred the patients were not being tracked during meals to ensure their location was known so their well-being could be monitored. He concurred these were unsafe practices.

10. On 8/18/21 at approximately 11:00 a.m. the CNO and NM acknowledged the doors to the nurses room were left open and at one point (over a one {1} minute period) the nurses station was unlocked and unattended. They concurred this was against policy and procedure and created an unsafe environment for the patients.