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Based on review of medical records and staff interview, it was determined the facility failed to ensure the rights of patients are being met in one (1) of four (4) medical records reviewed (#3 on identifier list). This has the potential to affect all patients by failing to allow them to exercise their rights and thereby receive care in a safe setting. This can result in, but is not limited to, patients having no or inadequate access to the grievance process or, reduced or no input into their plan of care, all of which can contribute to negative patient outcomes.

Findings include:

A review of the medical record of Patient #3 was conducted on 7/12/12.

1. On 6/11/12 at 2016 a nursing progress note states, "patient started talking to his mother about staff, writer reminded patient he wasn't supposed to discuss staff with his mother and that I would have to call the Unit to talk to the R.N. I asked the operator to call the unit and she did as I asked, I told the R.N. what had occurred and she told me to tell the patient that he has one more chance to comply with the rules."

2. On 6/18/12 at 2007 a nursing progress note states, Patient #3 was participating in an off unit visit with mother. The nursing progress note states Patient #3 "began complaining about a male Health Services Worker (HSW) he called by name and made a disparaging remark. I gave him (Patient #3) one verbal warning regarding this kind of behavior."

3. On 7/2/12 at 2224 per a nursing progress note, Patient #3 "had a visit with his mother today at 7 pm. Patient was continually reminded about talking about staff".

4. On 7/12/12 at 0858 an interview was conducted with the Quality Assurance/Performance Improvement Director (also the Staff Educator). She was asked why the patient would be told he was not allowed to discuss staff with his mother. She stated she did not know a reason why, but this patient had some specific stipulations under his "court order". While this interview was taking place, the Medical Director arrived. He was asked the same question. He stated the patient does have specific requirements regarding communication and visitation. He stated these restrictions are primarily related to when and how often the patient's family may visit him, and, patient's family interfering with the care of other patients. He further stated he would consult with another physician in the facility who is more directly involved with the patient's care regarding "where this came from".

5. On 7/12/12 at 1230 the Medical Director returned with a copy of the physician's order which was generated as a result of the court order restricting visitation. This order was reviewed with the Medical Director. He agrees this order does NOT state the patient is barred from discussing staff with his mother, the patient is barred from discussing other patients with his mother. He does not know why staff has interpreted this order in such a way that would result in them prohibiting the patient from discussing staff with his family.

Based on medical record review, staff interview and review of policy and documents it was determined the hospital failed to ensure one (1) of one (1) patients reviewed, who was on a sex offender registry, was released to a safe setting for potential discharge (patient #6). When allegations of patient abuse/neglect and exploitation in the discharge setting were made by this patient the hospital failed to report in accordance with policy and applicable State law. This failure creates the potential for the care and condition of all patients to be adversely affected.

Findings include:

1. Review of the 6/8/12 interim discharge summary and 6/11/12 progress notes for patient #6 revealed he was discharged to a group home setting with a need for twenty-four (24) hour supervision on 6/11/12.

2. Joint interview was conducted with the Admissions Director and Social Work Director at 0945 on 7/11/12. They both stated patient #6, who was on a sexual offender registry, was one of a total of five (5) patients who were returned to the hospital following a trial release to a transitional residential setting. The Directors stated that shortly after the patient left to go to this setting the hospital received an allegation that the residential supervisor had sexually molested one of these patients in the past. They stated upon further investigation it was learned that this supervisor had a criminal record. Further investigation revealed the transitional residential placement was not licensed.

The Directors stated that based on these safety concerns a decision was made to return these five (5) patients to the hospital as the hospital was still legally responsible for them. They stated the appropriate legal documents were obtained and hospital staff went to the local Judge and with the help of local law enforcement the patients were eventually located and returned to the hospital by hospital staff. The Directors stated when they contacted the Supervisor to make him aware the hospital staff was coming to return the patients, he was not cooperative and encouraged the patients to flee prior to the arrival of hospital staff.

Both Directors confirmed and provided documentation to support that patient #6 made an allegation he was drugged and sexually molested by the residential supervisor prior to his return to the hospital.

3. Review of the 6/12/12 Physician Note, entered at 1300 when the patient returned to the hospital, revealed in part: "He says that the residents were informed about the fact that Mildred Mitchell Bateman Hospital (MMBH) personnel were on their way to pick them up to go back to MMBH. The three (3) other residents were told that they did not have to go back to MMBH. Patient #6 was told that since his case was different from those of the others, he would have to remain at the residence but have to stay out of sight. Patient #6 was then told to go to the room of the supervisor and was locked in. After the MMBH personnel came and went, patient claims the supervisor came to the room and handed him a coke bottle. Patient claims he drank half of the content but he thought, being a lifelong Coke drinker that his drink did not taste like Coke. He claims that after a few minutes he started to feel woozy and weak. He then claims that the Supervisor groped him in the genital area and then proceeded to give him oral sex (fellatio). He claims that he tried to resist but that he was too weak and uncoordinated to thwart (supervisor). He claims that when it became dark, (Supervisor) brought him to his truck, instructed him to lie low until they got to Cabell county. (Supervisor) dropped him off on 9th avenue. He claims he walked to the Mission... He claims that because of persistent wooziness he was sent to Cabell Huntington Hospital by ambulance. He claims that he did not mention the sexual assault to ER (Emergency Room) physician. Patient does not look perturbed while talking about what happened in Hamlin. He claims he is feeling 'OK."

4. Review of the medical record revealed it included a copy of an Emergency Department (ED) record for the night of 6/11/12. This ED record reflected the patient was examined and treated for chest pain at a local hospital prior to returning to MMBH on 6/12/12.

5. The policy "Patient Abuse/Neglect, or Exploitation," last reviewed 12/28/10, was provided for review. The policy states in part: "It is the responsibility of all hospital staff to insure protection of all patients from physical and verbal abuse or any other infringement of their civil, human or legal rights and from neglect...Mildred Mitchell-Bateman Hospital will assure that any incident of abuse, neglect, exploitation, or harassment is reported and analyzed, and the appropriate corrective, remedial or disciplinary action occurs, in accordance with all applicable local, State and Federal law... Related Document/Reference: 'West Virginia Administrative Rules, Department of Health and Human Resources Series 59, Behavioral Health Client Rights.'"

6. Review of "West Virginia Administrative Rules, Department of Health and Human Resources Series 59, Behavioral Health Client Rights." reveals in part: "Staff should be aware of WV Code 27-12-3 which reads as follows: 'If any person shall entice any patient from any state hospital who has been legally committed thereto, or attempt to do so; or shall counsel, cause, influence, or assist, or attempt to do so; any such patient to escape or attempt to escape therefrom or harbor or conceal any such patient who has escaped therefrom; or shall, without permission of the superintendent of any such hospital, give or sell to any such patient, whether on the premises thereof or elsewhere, any money, firearms, drugs, cigarettes, tobacco, or any other article whatsoever; or shall receive from the hands of any such patient anything of value, whether belonging to the state or not; or shall cause influence or attempt to cause or influence any such patient to violate any rule or to rebel against the government or discipline of such hospital; or shall tease, pester, annoy, or molest any such patient, he shall be guilty of a misdemeanor, and, on conviction thereof, shall be fined not less than ten nor more than one hundred dollars, or imprisoned not exceeding six months, or, in the discretion of the court, both fined and imprisoned. If any person shall aid or abet the commission of any of the foregoing offenses, or aid or abet an attempt to commit the same, he shall be guilty of the same as if he were the principal, and be punished as above provided. In the trial of an indictment for committing any of the above-named offenses, the accused may be found guilty of an attempt to commit the same, or of aiding or abetting another in committing or in an attempt to commit the same. If any person, not her husband, shall have sexual intercourse with any female patient who is a patient of any of said state hospitals, he shall be guilty of a felony, and, on conviction thereof, shall be confined in the penitentiary not less than ten or more than fifteen years..."

7. At 0915 on 7/12/12 an interview was conducted with the Clinical Director. The residential supervisor's role in thwarting the efforts of hospital personnel to return the patients to the hospital and the reports the supervisor told and assisted patients to flee and hid patient #6 were discussed. Additionally the allegations of criminal acts by the Supervisor, which made by patient #6 and documented by hospital staff, were discussed. The Clinical Director stated the patient's allegations were reported to Adult Protective Services per policy.

He confirmed no report of the allegations of criminal wrongdoing was made to law enforcement officials. He indicated he was not aware of the requirements of the applicable State law: "West Virginia Administrative Rules, Department of Health and Human Resources Series 59, Behavioral Health Client Rights," which is referenced in the hospital Abuse policy.

Based on document review and interviews it was determined the facility failed to ensure patients are free from all forms of abuse or harassment in three (3) of four (4) patients with allegations of staff verbal abuse (#1, 2 and 3). This has the potential to affect all patients by failing to provide a safe and therapeutic environment conducive to positive patient outcomes.

Findings include:

1. Hospital policy titled: Patient Abuse/Neglect, or exploitation, states in part: "The use of language, tone or inflection of voice that would likely be construed by an impartial observer as a threat or harassment, derogation or humiliation of a patient. Verbal abuse includes, but is not limited to: the use of a threatening or abusive tone or manner in speaking to a patient; the use of derogatory, vulgar, profane, abusive or threatening language; verbal threats; teasing, pestering; deriding, harassing, mimicking or humiliating a patient; derogatory remarks about the patient, his or her family or associates; or sexual innuendo, sexually provocative language or verbal suggestion."
2. An interview was conducted with Health Services Assistant #9 (HSA) on 7/11/12 at 1555. She stated that on or about 6/14/12 (exact date unavailable, report date is 6/14/12). Patient #2 had two (2) cups of hot coffee in his hands. Adjunctive Therapy Staff #14 (ATS) "jerked" the cups out of the patient's hands and threw them in the trash while screaming, "You don't get them before the walk!" Patient #2 responded, "why are you screaming at me?" ATS #14 screamed again, "'cause you aren't supposed to have coffee!". An interview with ATS #10 was conducted on 7/11/12 at 1610. She reports hearing ATS #14 "screaming" at Patient #2. During the same interview of HSA #9 she states that on or about 6/14/12 (exact date unavailable; see above), HSA #9 states Patient #3 was "quietly watching TV and he wanted to turn the TV". ATS #14 was present and called Patient #3 a "Mama's Boy".

3. During the interviews of HSA #9 and ATS #10, it was also reported that ATS #14 frequently "nitpicks" Patients #1 and #2. He frequently calls patients derogatory names such as "bitch, queenie, mama's boy, fag, drama queen, fat ass and son of a bitch". They further report ATS #14 "does not like" Patients #2 and #3, and denies them privileges such as participation in activities or access to art supplies.

4. An interview was conducted with the Interim Director of Adjunctive Therapy (IDAT) on 7/11/12 at 1530. He states he has had concerns regarding ATS #14 being "verbally abusive" to patients and has witnessed ATS #14 denying patients privileges they are entitled to. He states ATS #14 "escalates" the behavior of patients by "giving it right back to them" and "not backing down". He states he has witnessed this behavior personally and reported this to his direct supervisor at the time (now deceased). He is unsure of the results of the outcome of that report, if any.

5. An interview was conducted with the Patient Advocate (PA) on 7/11/12 at 1007. She states there have been allegations regarding ATS #14 going back as far as "two years". She provided documentation dated 7/28/10 in which two (2) patients had made complaints regarding ATS #14 being "disrespectful" and "making me feel bad". At that time patients also complained about ATS #14 calling them "fat" and a "bitch". One of these complainants is Patient #3 referenced above.

6. An interview was conducted with Health Service Assistant #1 (HSA) on 7/11/12 1250 hour. She stated that on July 9, 2012 at approximately 1430 patient #1 was scheduled to go home and had become upset over his impending discharge and not having a ride home. The patient's scheduled ride had been turned away twice as discharge instructions were not complete. The patient went to his room and slammed the door. RN #3 went into the patients room without knocking and a verbal altercation ensued. HSA #1 overheard the RN say: "You will not be going home now."
7. During an interview with HSW #2 on 7/11/12 at 1415 she stated on 7/9/12 at approximately 1415 she was making rounds on the male end of the hall on unit A3 and heard yelling coming from patient #1's room between the patient and RN #3. She stated she heard RN #3 tell the patient "You will not be going home now, I will see to it that you will not be discharged."
8. An interview was conducted with the Licensed Practical Nurse (LPN) #12 on 7/11/12 at 1545. She stated she was in the medication room when she heard yelling and screaming. The LPN revealed she had heard the yelling between the RN #3 and the patient and felt the incident could have been handled in a more calming manner.

Based on review of medical records, staff and patient interview and hospital documents it was determined the hospital failed to ensure the patient's discharge plan addressed the need for obtaining legal identification (ID) documents, for one (1) of one (1) patients reviewed who was on a sexual offender registry (patient #6). This failure creates the potential for discharge needs of all patients to be unmet.

Findings include:

1. Interview was conducted with patient #6 at 1315 on 7/11/12. He stated he was being discharged that day. He stated he was waiting for hospital staff to provide him with a bus ticket. He stated hospital staff was going to give him a ride to the bus station and he would use the ticket to go to a neighboring city which had a homeless shelter where he could spend nights only. He explained the shelter is only open at night. Residents of the shelter must leave every morning and can return at night. When asked if he had plans for a job or access to money, he stated he had no legal ID but had been told the staff at the homeless shelter might assist him with obtaining an ID. He acknowledged he was required to register as a sexual offender but could not do so until he obtained an ID.

2. Review of the medical record revealed patient #6 was admitted on 5/28/12. The record confirmed the patient had a 7/11/12 discharge order and order for purchase of a bus ticket. Further review of the record revealed this was the fourth discharge order written for this patient in the past month. The following is a summary of information gained from the record regarding these four (4) discharges:

a. On 6/11/12 the patient was discharged to a group home setting in Lincoln county. The patient was taken to the State Police to register as a sexual offender on his way to the group home. The police were unable to register the patient and he was told to return and register on Wednesday 6/13/12. The patient was then left at the group home. Due to multiple safety concerns related to the group home and supervisor in the home, hospital staff returned to retrieve the patient the same day and return him to the hospital. The patient eloped and returned to the hospital on 6/12/12.

b. On 6/22/12 the patient was discharged to a motel in Kanawha county. The patient was taken to the State Police to register as a sexual offender on his way to the motel. He could not register at the State Police or pay for the room at the motel due to having no state identification, birth certificate or social security card. Therefore patient #6 returned to the hospital the same day.

c. On 7/6/12 a discharge order was written for 7/9/12. On 7/9/12 this order was canceled. The record reflects that just moments before discharge the staff and treatment team discovered the home setting was inappropriate. This proposed setting was to have been a friend's home in Logan county. The 7/6/12 discharge plan reflected the hospital was making the friend responsible to help the patient get identification following discharge so that he could be registered with the State Police in Logan county.

d. On 7/11/12 the patient was taken to the local bus station and given a bus ticket to go to a neighboring city. The 7/10/12 discharge plan for this discharge noted: "Needs to immediately obtain ID to be able to fulfill his legal obligation to register on the West Virginia (WV) Sex Offender's registry with WV State Police."

The patient's record reflected no effort was made by the hospital to assist the patient in obtaining legal ID, in order to assist with the patient's discharge plan, prior to any of these discharges.

3. Interview was conducted with Social Worker for patient #2 at 1400 on 7/11/12. She confirmed that patient #6 was on a sexual offender registry. She also confirmed he had no legal identification and therefore no way to register as a sexual offender as required and no financial resources or way to access any financial resources as he had no legal identification documents. She acknowledged the patient's lack of identification posed a challenge and barrier to discharge. The Social Worker could provide no documentation to reflect the hospital assisted or attempted to assist the patient in obtaining legal ID.

4. The job description for Social Worker, approved date 5/14/07 was provided for review. It lists Essential Duties and Responsibilities, in part, as: "Participate as a member of the interdisciplinary treatment team to coordinate efforts of the Treatment Team in development and implementation of patient's treatment and discharge plan...Act as a patient advocate to facilitate patient access to concurrent, continuing or community based services...Maintain contact with community liaison/support providers and assist in referring/application procedures toward patient access to community resources."

5. At 1215 on 7/12/12 this record was reviewed and discussed with the Director of Social Work. She acknowledged the record failed to reflect the hospital staff assisted or attempted to assist the patient with his ongoing discharge need for obtaining legal ID. She acknowledged the patient had no access to finances at the time of discharge nor could he register as a Sexual Offender as required by law due to no legal ID.

Based on review of medical records and other documents and interview with staff, it was determined the hospital failed to establish an appropriate discharge plan for at least four (4) of five (5) discharged records reviewed. (Patients #5, 7, 8 and 9). Those patients were discharged to a residential facility which was not licensed as a behavioral health facility in accordance with established hospital policy. Also, the hospital failed to determined the appropriate level of supervision needed by each of the four (4) patients after discharge to a residential facility. This deficient practice has the potential for the hospital to discharge the patients to an unsafe and/or inappropriate setting.

Findings include:

1. Review of the hospital's policy "Discharge Plans", last reviewed/revised 4/4/12, revealed the policy states "Interdisciplinary Treatment Teams shall ensure that patients discharged from Mildred Mitchell-Bateman Hospital are referred to safe, therapeutic and supportive environments. Third party supervised residential sites (those other than independent residence or living with family/friends) must be registered, approved or licensed by the West Virginia Department of Health and Human Resources (DHHR) in order to meet patient's aftercare and daily living needs."

2. A staff Social Worker (SW) and the Director of Social Services were interviewed jointly on 7/11/2012 at 14:20. The SW stated that on Friday 5/25/2012, a man presented to the admissions desk at the hospital and requested to speak to the SW assigned to patient #5. She stated she was the assigned SW for that patient, and she was informed the visitor wanted to speak with her. She stated she was busy at that time and could not meet with him, but she called him later that day to speak with him. She stated the man informed her that he had met patient #5 "through meetings" at the "Oxford House", which she stated is an unlicensed residential setting for the treatment of substance abuse. She stated the caller informed her that he had just opened a "transitional living home" under the name of "Pathway" or "Pathways" in Hamlin, WV and he would like to take patient #5 (upon discharge from the hospital). The SW stated she informed the caller she would have to speak with patient #5 and obtain his consent to discuss him and his potential discharge with the caller. The SW stated she obtained that consent from the patient. She stated the caller then visited the patient at the hospital on that weekend.

Review of the visitor sign in sheet for patient #5 revealed the caller visited the patient on 5/28/2012 between 13:10 and 15:00.

The SW and the Director of Social Services stated the hospital did not confirm the actual existence of the "Pathway" facility or if the facility was licensed as a provider of services. They both stated the patient only needed "support" and not "supervision" after discharge, and the type of setting described by the caller/supervisor of the Pathway facility seemed to fit the needs of the patient. They stated their understanding of the "facility" was that it was a "transitional living" residential home, with only support and not supervision, in which a person would pay his/her own rent and be expected to follow certain rules established by the facility, including attending substance abuse meetings provided in the community. They stated the patient agreed to be discharged to the facility and the person who had initially contacted the hospital came to pick up the patient and transported him to the residential facility on 5/31/2012.

The SW stated that prior to the patient's discharge, she was visiting the Hamlin, WV area and she drove by the house which was described to her as being the "Pathway" facility, and she thought it was a "nice" home to discharge the patient to.

The Director stated the hospital determined on 6/11/2012 the residential facility was not licensed or approved. She stated patient #5 was picked up by hospital staff and returned as an inpatient in the hospital on 6/11/2012, due to the determination the residential setting was not appropriate for the patient.

3. Review of the medical record for patient #5 revealed the "Interim Discharge Summary" was written on 5/30/2012. The Director of Social Services stated during interviewed on 7/12/2012 at 14:30 that the Interim Discharge Summaries are the interdisciplinary "plans" for each patient. On the summary for patient #5, it was noted the 31 year old male patient had been admitted on 5/14/2012. It was noted the patient left the hospital on 5/31/2012 on a "7 day pass to trial visit". The form listed the "Type of Residence" as "Substance abuse/Residential. Number of Hours/Day Supervision Needed: As determined by the Pathways staff. Comments: Patient is being discharged to the Pathways House in Hamlin, WV."

The record was reviewed with the Director of Social Services on 7/12/2012 at about 14:40. She acknowledged that it had been discussed on 7/11/2012, and she and the patient's assigned SW had stated the patient only needed "support" and not "supervision". She concurred during review of the medical record that the patient's discharge plan actually stated the patient needed a "substance abuse/residential" setting with "supervision as determined by the Pathways staff." She also concurred it was the hospital's responsibility to determine the level of supervision needed after discharge when formulating each patient's discharge plan.

4. Reviews of the medical records for patients #7, 8 and 9 revealed the patients were all discharged on 6/7/2012 to the same residential "Pathway" home. The discharge plans for patients #7, 8 and 9 revealed the "Type of Residence" needed for each was "Transitional Living" with supervision "As determined by the staff" (of the residential home). The records documented that the supervisor of the residential home had come to the hospital to pick up and transport the patients to the home upon discharge. The records were reviewed with the Director of Social Services on 7/12/2012 at about 14:40. She concurred it was the hospital's responsibility to determine the level of supervision needed after discharge when formulating each patient's discharge plan.

5. Review of the medical record for patient #9 revealed the 22 year old patient had been admitted on 5/11/2012 with a diagnosis of schizophrenia and Asperger's Disorder. The patient presenting symptoms included "Patient was aggressive, violent, threatening, and endorsing auditory hallucinations in the context of ongoing family conflict." The patient was discharged to the "Pathway" residential home on 6/7/2012 with a follow-up appointment made with community mental health on 6/11/2012. Reviews of information in the re-admission medical record on 6/9/2012 revealed the patient was in the street in front on the home on 6/9/2012 and was out of control. Police officers had to be called to restrain the patient and to transport him back to the hospital.

The only documentation in the medical record to support the hospital's interdisciplinary team's decision to discharge the patient to the "Pathway" residential home was "Patient needs some structure, therefore this program seems to fit his residential needs", which was written on his discharge plan. The Director of Social Services was interviewed on 7/11 and 7/12/2012 in the afternoon of each day. The patient's assigned Social Worker was also interviewed on 7/11/2012 at about 14:20. They were asked to provide documentation relative to the services available or the level of supervision/support available at the Pathway residential facility. They stated they did not have any documentation, nor had they seen or reviewed any written description of services or supervision offered at the facility. They stated they had not attempted to confirm if the Pathway residential facility was licensed as a behavioral health facility in the state of West Virginia. They stated it was determined after the patient was returned to the hospital that the residential facility was not licensed, as the hospital policy requires.

6. The Director of Social Services and the Director of Admissions were interviewed on 7/11/2012 at 09:45. They stated that the aunt of patient #7 made a telephone call to the Director of Admissions on 6/11/2012. The patient's aunt stated she had visited patient #7 at the residential home on the previous day. The aunt stated she recognized the residential home supervisor as a person who allegedly had sexually abused patient #7 in 2005, when he was 16 years old. She stated she wanted patient #7 removed from the residential home. The Directors stated the hospital immediately launched an investigation into the residential home and the person who was supervising the home. The Lincoln county Sheriff's office confirmed the supervisor of the residential home had a "criminal record". The hospital took steps with the assistance of a local judge and local law enforcement to retrieve patient #5, 7 and 8 from the residential facility on 6/11/2012. Those patients were readmitted to the hospital.