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Based on document review, medical record review and interview it was revealed the hospital's governing body failed to ensure group therapy treatments were continued on the COVID-19 Unit for two (2) of ten (10) patients (patients #5 and 12) and failed to communicate with the Medical Director when a violent patient without COVID-19 was transferred to the empty COVID-19 Unit. The failure to provide ordered group therapies on the COVID-19 Unit and the failure to communicate patient placement decisions to the Medical Director has the potential to adversely affect all patients on the COVID-19 Unit.

Findings include:

A review of the document entitled "Bylaws of the Governing Board of William R. Sharpe, Jr. Hospital (Sharpe Hospital)" approved 1/16/19 revealed in part: "Under the authority conferred upon him by WV Code 27-1-7 and consonant with its expressed aims and policies, the CEO (Chief Executive Officer) will be responsible for the management of Sharpe Hospital. The Governing Board will hold the CEO accountable for the application and implementation of established policies to the operation of the hospital and for providing liaison between the Governing Board and the departments of the hospital ...The CEO shall ensure effective communication ...between members of the Governing Board, the Medical Staff and Hospital Administration."

A review of patient #5's medical record revealed the treatment plan included, "Mental Health Therapist (MHT): is scheduled to attend Better Tomorrows group twice weekly ..." On 12/09/21 the patient, while under two to one (2:1) close constant observation, attacked a patient with intellectual disability disorder, and resulted in the patient having a broken nose. After the attack the patient remained aggressive and was placed in mechanical restraints. After the patient was released from restraints, the patient was transferred to Unit Charlie-Two (C2), the COVID Unit, for the safety of the other patients. The patient was on Unit C2 from 12/09/21 through 12/14/21, and remained three-to-one (3:1) observation. There were no other patients on Unit C2 during that time. A MHT progress note dated 12/14/21 states, "Group: (Better Tomorrows) Response; Excused from group. (Patient #5) has been temporarily transferred to C-2 due to aggressive/violent behaviors." No documentation is noted the patient received alternative one on one (1:1) materials for this group while on Unit C2.

A review of patient #12's medical record revealed the patient's master treatment plan included, "...MHT will provide Cinematic Therapy two (2) days per week ....MHT will provide (patient #12) with Healthy Lifestyles Group two (2) days per week ..." The patient's record reflected that the patient attended both groups regularly. The patient tested positive for COVID-19 on 12/14/21 and was transferred to Unit C2. A MHT note dated 12/20/21 at 12:11 p.m. states, "(Patient #12) is on the COVID-Unit (C2). (Patient #12) tested positive on 12/13/21. Until (patient #12) can return to E1 (Edward-One), (patient #12) will not be attending Cinematic Therapy and Healthy Lifestyles." No documentation is noted the patient received alternative 1:1 materials for this group.

An interview conducted with the Medical Director on 12/20/21 at 3:00 p.m. revealed they did not know patient #5 had been moved to Unit C2 until the following Monday when a call was received to admit a patient who had been diagnosed with COVID-19. Then the Medical Director was told by the CEO they would need to move a patient off of the C2 Unit before admitting a patient with COVID-19.

An interview was conducted with the CEO on 12/21/21 at 8:15 a.m. who stated, "They have been told they have to continue group therapy on the COVID Unit." The CEO agreed they were not aware it was not being done. The CEO stated the Medical Director was not here when patient #5 was moved to the empty COVID Unit and the CEO thought the information would be forwarded to the Medical Director by the patient's provider.

Based on document review, medical record review and interview it was revealed the medical staff failed to follow their bylaws and rules and regulations for two (2) of ten (10) patients (patients #5 and 12) who were ordered group therapy treatments but were not receiving the therapy on the COVID-19 Unit. This failure has the potential to adversely affect all patients admitted or transferred to the COVID-19 Unit.

Findings include:

A review of the document entitled "William R. Sharpe, Jr. Hospital Medical Staff Bylaws" approved 11/4/19 revealed in part: "Appendix D, Medical Staff Rules and Regulations ... A member of the Active or Associate Medical Staff shall be responsible for the diagnosis, treatment and medical care of each patient within the Hospital. ...The physician will be involved in the development and implementation of the treatment plan and assure sufficient discipline participation in the formulation of a treatment plan that meets the patient's needs ..."

A review of patient #5's medical record revealed the treatment plan contained an order for "Mental Health Therapist (MHT): [patient #5] is scheduled to attend Better Tomorrows group twice weekly ..." The patient was transferred to the COVID-19 Unit after a violent outburst. The COVID-19 Unit was empty during patient #5's stay. Further review of the medical record revealed documentation from the MHT on 12/14/21 which stated, "Group: (Better Tomorrows) Response: Excused from group. [Patient #5] has been temporarily transferred to C-2 due to aggressive/violent behaviors." There was no documentation in the medical record the patient was given information regarding the group meeting.

A review of patient #12's medical record revealed the treatment plan contained an order for the MHT to provide the patient with Healthy Lifestyles Group two (2) days per week and Cinematic Therapy two (2) days per week. Patient #12 was transferred to the COVID-19 Unit on 12/14/21 after testing positive for COVID-19. The medical record revealed a note from the MHT stating "(Patient #12) is on the COVID Unit (C2). (Patient #12) tested positive on 12/13/21. Until (patient #12) can return to E1 (Edward-One), (patient #12) will not be attending Cinematic Therapy and Healthy Lifestyles." Further review of the medical record revealed no alternatives were offered for the missed group therapies.

An interview conducted with the Medical Director and Director of Advanced Practice on 12/20/21 at 3:00 p.m. revealed they agreed group therapies should have been continued for patients transferred to the COVID-19 Unit. The Medical Director stated they thought laptops were being used to conduct the group therapies.

A. Based on medical record review, document review and interview it was revealed the facility failed to follow policies and procedures for documentation in one (1) out of twelve (12) patients (patient #5). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #5. On 12/09/21 the patient was placed in mechanical restraints. The "restraint and seclusion record" documentation revealed the patient remained in restraints from 11:15 a.m. through 2:20 p.m. Vital signs were recorded at 11:17 a.m., 11:20 a.m. and 12:08 p.m. It is documented the patient was offered to void at 12:35 p.m. The patient was fed lunch at 1:05 p.m. No further documentation of fluids offered, toileting offered, ROM (range of motion) circulation checks or skin care was documented.

A policy titled "Guidelines for Restraints and Seclusions," last revised 09/13/19, was reviewed and the policy states in part: "...3. Observation and Monitoring of the Patient in Seclusion/Restraint:... i. The patient will be assessed and documented by a staff member trained and competent in the use of restraint and seclusion every one (1) hour for the following: vital signs, hygiene and elimination, fluids offered. J. There shall be an hourly assessment of the continued need for seclusion or restraints by the RN (Registered Nurse) of the unit or shift throughout the duration of the seclusion or restraint. RN will document the following, includes, but not limited to:...2. Circulation and range of motion in the extremities."

An interview was conducted with RN #3 on 12/21/21 at 10:33 a.m. Regarding patient #5's "Restraint and Seclusion record," RN #3 concurred it was not filled out correctly according to policy.


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B. Based on document review, medical record review and interview it was revealed nursing services failed to follow their policies and procedures for three (3) of ten (10) patients (patients #1, 4 and 5) by not following the Employee Code of Conduct. The failure to abide by the Employee Code of Conduct has the potential to affect all patients admitted to the hospital.

Findings include:

A review of the facility policy entitled "Employee Conduct" effective date 9/8/20 revealed in part: "Avoid physical abuse, harassment, exploitation or intimidation of patients ...Refrain from making unwanted or inappropriate verbal or physical contact with patients ...Refrain from making unwanted or inappropriate sexual advances, either verbal or physical to patients ..."

A review of a document titled "Adult Protective Services (APS) Mandatory Reporting Form" revealed an APS complaint form was filed on patient #4's behalf on 11/17/21 alleging Health Service Worker (HSW) #1 touched patient #4 sexually over a period of weeks. During the investigation it was revealed HSW #1 received calls on their personal phone from patient #4 multiple times. This was confirmed by hospital phone records. During one (1) of the phone calls, HSW #2 watched patient #4 dial HSW #1's phone number and heard HSW #1's voice (which HSW #2 recognized) on the other end of the phone. HSW #2 overheard content of a sexual nature being discussed.

An interview conducted with HSW #4 on 12/20/21 at 12:45 p.m. revealed HSW #4 was present when patient #1 was attacked by patient #5. Patient #1 had been knocked to the floor and was unconscious for a few seconds. HSW #4 heard Registered Nurse (RN) #5 say "there's nothing wrong with him" and "he was faking."

An interview conducted with HSW #5 on 12/20/21 at 2:00 p.m. revealed HSW #5 witnessed patient #5 attack patient #1. HSW #5 stated patient #1 had bruising over the right side of their face and patient #1 stated "felt like something coming out of my ear." HSW #5 stated RN #5 said "he's faking" and kind of "kicked him" to move him.

An interview conducted with HSW #6 on 12/20/21 at 2:35 p.m. revealed HSW #6 had responded to a support call. HSW #6 stated they were trying to calm patient #5 down. HSW #6 stated patient #5 was made a two to one (2:1) close constant observation (CCO) and had calmed down so the support team left. Another support call happened five (5) minutes later because patient #5 was threatening to hit someone. RN #5 came in the room to give patient #5 "a shot." Patient #5 did not want RN #5 to give the "shot." Another nurse came and gave the patient the medication. HSW #6 stated RN #5 was "running at the mouth and getting aggravated and triggering the patient." HSW #6 asked RN #5 to leave the room. HSW #6 stated RN #5 was "having a battle with him (patient #5) basically."

An interview was conducted with the Chief Nursing Officer (CNO) on 12/21/21 at 2:00 p.m. and she agreed the Employee Code of Conduct was not followed by the nursing staff.

Based on medical record review, document review and interview it was revealed the facility failed to ensure therapeutic services were provided according to the patient's treatment plans in two (2) out of twelve (12) patients (patient #5 and 12). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A review of patient #5's medical record revealed patient #5 was admitted to the facility on 09/22/21. The treatment plan included, "Mental Health Therapist (MHT): (Patient #5) is scheduled to attend Better Tomorrows group twice weekly ..." On 12/09/21 the patient was transferred to Unit Charlie-Two (C2) for the safety of other patients. The patient was on Unit C2 from 12/09/21 through 12/14/21. A MHT progress note dated 12/14/21 states, "Group: (Better Tomorrows) Response: Excused from group. (Patient #5) has been temporarily transferred to C2 due to aggressive/violent behaviors." No documentation is noted the patient received alternative one on one (1:1) materials for this group while on Unit C2. The patient was then transferred to Unit Charlie-One (C1) where group therapy was continued and he remains for treatment.

A review of patient #12's medical record revealed the patient was involuntarily admitted to the facility on 09/26/21. The patient's master treatment plan included, "...MHT will provide Cinematic Therapy two (2) days per week ....MHT will provide (patient #12) with Healthy Lifestyles Group two (2) days per week ..." The patient's record reflected that the patient attended both groups regularly. The patient tested positive for COVID-19 on 12/14/21 and was transferred to Unit C2. A MHT note dated 12/20/21 at 12:11 p.m. states, "(Patient #12) is on the COVID Unit (C2). (Patient #12) tested positive on 12/13/21. Until (patient #12) can return to E1 (Edward-One), (patient #12) will not be attending Cinematic Therapy and Healthy Lifestyles." No documentation is noted that the patient received alternative 1:1 materials for this group. The patient remains on unit C2.

A document listing all patients on each unit and their daily schedules was reviewed for 12/21/21. Unit C2 lists three (3) patients, including patient #12. The patients have no scheduled group therapies on this unit.

An interview was conducted with the Chief Executive Officer (CEO) on 12/20/21 at 9:10 a.m. Regarding patient #5, the CEO stated, "When (patient #5) was transferred, the treatment plan remains in place, so the same services should have been provided."

An interview was conducted with the MHT on 12/20/21 at 1:29 p.m. Regarding continued group therapy for patient #5, the MHT stated, "We follow the patients when they are moved to Unit C2, but do not continue group therapy. I wasn't quite sure what we were doing with (patient #5) because he had just been moved and did not have COVID-19."

An interview was conducted with the Medical Director and the Lead Nurse Practitioner on 12/20/21 at 3:00 p.m. Regarding group therapy, the Medical Director stated, "Group therapy should have continued for any patient moved to the COVID-19 Unit. I was told things would have continued either by video or alternative 1:1 group therapies."

A telephone interview was conducted with Registered Nurse (RN) #4 on 12/20/21 at 3:23 p.m. Regarding group therapies on unit C2, RN #4 stated, "The patients will see their treatment team and their providers. The MHT will see the patients for 1:1 therapies on the unit. There are no group therapies. The MHT does not bring group therapy materials. The group therapy remains on the patient's treatment plans until they are transferred off this unit."

An interview was conducted with the CEO on 12/21/21 at 8:16 a.m. Regarding group therapies on the COVID-19 Unit C2, the CEO stated, "What we told them is that they have to continue in group."