HospitalInspections.org

Based on a review of documents and interview it was revealed the facility failed to report verbal abuse of patient #1 to Adult Protective Services (APS) when the abuse occurred in one (1) of one (1) APS not filed. These failures place all patients receiving care at the facility at risk for harm, serious injury or death from unreported incidents of abuse. (See tags A 144 and A 145).

A. An Immediate Jeopardy to Patient Rights (Care in a Safe Setting) was called on 1/11/21 at 7:37 p.m. because the facility failed to ensure care was being provided in a safe setting. The Licensed Professional Nurse (LPN) verbally abused patient #1 on 11/8/20. The advocate's investigation into the event revealed RN #1 knew about the incident but did not file an APS referral form. The LPN was not removed from duty until after she worked a shift on 11/12/21, the date the incident was reported and the APS referral was made. RN #1 was not counseled or removed from duty for failure to report the abuse.

B. Serious Injury, harm, serious impairment or death: The potential exists that other occurrences of abuse identified by RN #1 would not be reported so they could be investigated and corrective action taken.

C. Need for Immediate Action: Patients are at risk for injury, harm, or death from unreported cases of abuse.

Based on a review of documents and interview it was revealed the facility failed to report verbal abuse to patient #1 to Adult Protective Services (APS) when the abuse occurred in one (1) of one (1) APS not reported . These failures place all patients receiving care at the facility at harm for serious harm, injury or death from unreported incidents of abuse.

1. A review of a document titled "LEGAL AID OF WEST VIRGINIA" dated 11/18/20 revealed the Behavioral Health Advocate interviewed RN #1 on 11/16/20 at 1:48 p.m. A review of the interview revealed RN #1 was aware verbal abuse occurred to patient #1 on 11/8/21.

A review of a document titled "STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF HEALTH FACILITIES WILLIAM R. SHARPE, JR. HOSPITAL MEMORANDUM" dated 11/18/20 revealed the Chief Executive Officer (CEO) sent a memo to the patient advocate on 11/18/20 acknowledging an investigation being conducted by the hospital and that the advocate's investigation report would in part, "...be considered part and parcel to our quest to address this matter wholly..."

2. An interview was conducted with the CEO on 1/11/21 at 5:00 p.m. He stated in part, "I did not read the entire investigation submitted to me by the advocate relative to alleged verbal abuse inflicted by the LPN on patient #1 on 1/8/21. I usually just reads the summary and conclusion of their investigation. I unaware RN #1 knew about the abuse when it occurred but did not file an Adult Protective Services (APS) referral form or report the abuse to her supervisor." He acknowledged RN #1 had not been re-educated or removed from duty. He acknowledged that without re-education the potential exists that other occurrences of abuse identified by RN #1 would not be reported so they could be investigated and corrective action taken. He acknowledged this was a violation of care in a safe setting and nursing supervision of care.

Based on a review of documents and interview it was revealed the facility failed to report verbal abuse to patient #1 to Adult Protective Services (APS) when the abuse occurred in one (1) of one (1) APS not reported . These failures place all patients receiving care at the facility at harm for serious harm, injury or death from unreported incidents of abuse.

1. A review of a document titled "LEGAL AID OF WEST VIRGINIA" dated 11/18/20 revealed the Behavioral Health Advocate interviewed RN #1 on 11/16/20 at 1:48 p.m. A review of the interview revealed RN #1 was aware verbal abuse occurred to patient #1 on 11/8/21.

A review of a document titled "STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF HEALTH FACILITIES WILLIAM R. SHARPE, JR. HOSPITAL MEMORANDUM" dated 11/18/20 revealed the Chief Executive Officer (CEO) sent a memo to the patient advocate on 11/18/20 acknowledging an investigation being conducted by the hospital and that the advocate's investigation report would in part, "...be considered part and parcel to our quest to address this matter wholly..."

2. An interview was conducted with the CEO on 1/11/21 at 5:00 p.m. He stated in part, "I did not read the entire investigation submitted to me by the advocate relative to alleged verbal abuse inflicted by the LPN on patient #1 on 1/8/21. I usually just reads the summary and conclusion of their investigation. I unaware RN #1 knew about the abuse when it occurred but did not file an Adult Protective Services (APS) referral form or report the abuse to her supervisor." He acknowledged RN #1 had not been re-educated or removed from duty. He acknowledged that without re-education the potential exists that other occurrences of abuse identified by RN #1 would not be reported so they could be investigated and corrective action taken. He acknowledged this was a violation of care in a safe setting and nursing supervision of care.

Based on document review it was revealed the facility failed to provide Registered Nurse (RN) #1 supervision for one (1) out of thirty (30) patients reviewed (patient #1). This failure resulted in actual harm to patient #1. This failure places all patients at risk for harm from care which is unsupervised by an RN. (See tags A 395 and A 398)

Based on document review it was revealed the facility failed to provide Registered Nurse (RN) #1 supervision for one (1) out of thirty (30) patients reviewed (patient #1). This failure resulted in actual harm to patient #1. This failure places all patients at risk for unsupervised care resulting in serious harm, injury or death.

Findings include:

1. A review of a document titled "LEGAL AID OF WEST VIRGINIA" dated 11/18/20 revealed the Behavioral Health Advocate interviewed RN #1 on 11/16/20 at 1:48 p.m. A review of the interview revealed RN #1 was aware verbal abuse occurred to patient #1 on 11/8/21. A review of the document revealed the abuse occurred in the day area which was visible to RN #1 from the nurse's station. The document stated RN #1 was told by the Licensed Practical Nurse (LPN) she had told patient #1 he was in part, "...on the road to getting medicated, um, for that behavior." RN #1 stated to the investigator she told the LPN the discussion should not have occurred in the day room. The document revealed the advocate read the definition of verbal abuse from Title 64.59 to RN #1. She then asked RN #1 if she felt the LPN verbally abused patient #1. RN #1 replied, "Well, telling somebody that kind of behavior is going to lead to medication, I would feel that way." A review of the document revealed patient #1 was interviewed on 11/13/20 at approximately 11:00 a.m. as part of the investigation. He stated in part, "...he was forced to apologize to {Health Service Worker #1} in the day area". The advocate asked patient #1 how he felt when he was told to apologize. Patient #1 replied, "I guess embarrassed."

2. A review of a document titled "Unit: C1 Day Shift Assignments" dated 11/8/20 revealed RN #2 was assigned as Charge Nurse on dayshift. The document revealed RN #1 was assigned as the second RN.

3. A review of patient #1's clinical record revealed there were no nurses notes from either RN #1, who witnessed the event, nor RN #2, who was in charge of the unit, regarding the incident.

4.A review of a document titled "Assigning and Supervising the Nursing Care of the Patient," effective date 3/7/19, revealed it states in part: "The shift RN is responsible for supervising staff..."

5. An interview was conducted with the Chief Executive Officer on 1/11/21 at 5:00 p.m. he concurred with the above findings.

A review of documents revealed the facility failed to ensure all nursing staff were following policies and procedures for ensuring patient's rights to be free from all forms of abuse. This failure resulted in actual harm to one (1) out of thirty (30) patients reviewed (patient #1). This failure places all patients at risk for serious harm, injury or death.

Findings include:

1. A review of a document titled "LEGAL AID OF WEST VIRGINIA" dated 11/18/20 revealed the Behavioral Health Advocate interviewed Registered Nurse (RN) #1 on 11/16/20 at 1:48 p.m. A review of the interview revealed RN #1 was aware verbal abuse occurred to patient #1 on 11/8/21. A review of the document revealed the abuse occurred in the day area which was visible to RN #1 from the nurse's station. The document stated RN #1 was told by the Licensed Practical Nurse (LPN) she had told patient #1 he was in part, "...on the road to getting medicated, um, for that behavior." She stated to the investigator she told the LPN the discussion with patient #1 should not have occurred in the dayroom. The document revealed the advocate read the definition of verbal abuse from Title 64.59 to RN #1. She then asked RN #1 if she felt the LPN verbally abused patient #1. RN #1 replied, "Well, telling somebody that kind of behavior is going to lead to medication, I would feel that way." A review of the document revealed patient #1 was interviewed on 11/13/20 at approximately 11:00 a.m. as part of the investigation. He stated in part, "...he was forced to apologize to {Health Service Worker #1} in the day area". The advocate asked patient #1 how he felt when he was told to apologize. Patient #1 replied, "I guess embarrassed."

A review of a document titled "STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH AND HUMAN RESOURCES OFFICE OF HEALTH FACILITIES WILLIAM R. SHARPE, JR. HOSPITAL MEMORANDUM" dated 11/18/20 revealed the Chief Executive Officer (CEO) sent a memo to the patient advocate on 11/18/20 acknowledging an investigation being conducted by the hospital and that the advocate's investigation report would in part, "...be considered part and parcel to our quest to address this matter wholly..."

A review of a document titled "Verbal, Physical, and Sexual Abuse of Patients, and Neglect," effective date 10/11/19, revealed it states 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." The document states in part: "..verbal abuse includes, but is not limited to the use of threatening or abusive tone or manner in speaking to a patient...humiliating a patient."

2. An interview was conducted with the CEO on 1/11/21 at 5:00 p.m. He stated in part, "I did not read the entire investigation submitted to me by the advocate relative to alleged verbal abuse inflicted by the LPN on patient #1 on 1/8/21. I usually just reads the summary and conclusion of their investigation. I unaware RN #1 knew about the abuse when it occurred but did not file an Adult Protective Services (APS) referral form or report the abuse to her supervisor." He acknowledged RN #1 had not been re-educated or removed from duty. He acknowledged that without re-education the potential exists that other occurrences of abuse identified by RN #1 would not be reported so they could be investigated, and corrective action taken. He acknowledged this was a violation of care in a safe setting and nursing supervision of care.