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Based on interview and review of facility's records, by-laws and policies, the facility failed to meet the Condition of Participation (CoP) for Governing Body. Specifically, the facility failed to ensure three of six sampled patients (P) (P1, P2, and P4) received care in a safe setting; the facility failed to implement preventive actions that resulted in P1's suicide death; the self-injurious behavior of P4 and P2's elopement from the secure, fenced facility's grounds.

The facility's failure identified an Immediate Jeopardy (IJ) (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death).

On 04/07/20 at 7:30 PM, the Chief Executive Officer (CEO) was notified that an Immediate Jeopardy existed at Patient Rights in Safe Setting (A-144), Patient Safety (A-286), and Registered Nurse Supervision of Nursing Care (A-395). The facility failed to ensure that nursing personnel provided care according to the assessed needs for three of six sampled patients (P) (P1, P2, and P4) and that the patients received the care and services in a safe setting. Specifically, the facility failed to implement preventive actions which resulted in P1's suicide death; the facility failed to implement one-to-one (1:1) supervision, in that P4 conducted self-injurious behaviors that required hospital admission and surgery to remove a metal wire from P4's arm; and failed to protect P2 when outside with facility staff in the facility's fenced area, was left unsupervised by the facility's staff, went over the fence and eloped from the facility's property.

The facility provided an acceptable plan for removal of the Immediate Jeopardy on 04/09/20 at 5:00 PM. The facility's plan for removal of the Immediate Jeopardy included the training and monitoring of the facility's staff to ensure appropriate levels of supervision were maintained, documented, and monitored by the Chief Nursing Officer (CNO) and the Quality Management Department of the hospital. The facility's removal plan further included the Medical Staff's reassessment of all patients receiving care in the facility to determine their risk of suicide and self-injurious behavior. In addition, the removal plan included the installation of a new fence in a courtyard of the facility to prevent elopement. The removal plan required the Quality Management Department of the facility to provide daily reports to the CEO of the facility and requires monthly reports to be provided to the Governing Body of the hospital.

The facility's removal plan was validated by surveyors while on-site and submitted on 04/09/20 at 5:25 PM. The facility's removal plan was approved on 04/09/20 at 5:27 PM, at which time the CEO and Medical Director were notified.

Findings include:

1. Review of the facility's organizational chart dated 07/24/19 revealed the CEO of the hospital was responsible for the overall operation of the facility. Review of the facility's document titled, "Functional Job Description", signed by the CEO on 02/23/16 indicated the CEO of the facility was responsible to, " ...ensure compliance with federal and state regulatory requirements including but limited to goals of patient care, safety, education ..."

Review of the facility's by-laws titled, "By-laws of the Governing Board of William R. Sharpe Jr. Hospital", dated approved by the hospital's Governing Board on 01/16/19, defined the role of the CEO as, "appointed by the Secretary of the Department of Health and Human Resources and represents the Governing Board, acting as its agent in the overall administrative management of Sharpe Hospital." In addition, Article Seven, Section One of the by-laws indicated, "The Governing Board will hold the CEO accountable for the application and implementation of established policies to the operation of the hospital and providing liaison between the Governing Board and the departments of the hospital. The CEO shall be charged with organizing the supporting committees to perform facility-wide functions in Management, Quality Improvement ...Safety, Risk Management ..."

2. The facility failed to provide care in a safe setting for P1, P2, and P4. The facility failed to ensure visual checks were completed for P1 which resulted in P1's suicide death. The facility failed to ensure adequate supervision was provided to P2 which resulted in the elopement of P2 from the facility's fenced grounds while in the presence of the Mental Health Specialist. P2 was returned to the facility by local law enforcement 1 hour and 22 minutes later. The facility failed to prevent P4, while on 1:1 supervision, from engaging in self-injurious behavior, which required surgical intervention to remove the mental wire from P4's arm.

The facility's failure affected the ability of the hospital to appropriately identify patients with suicidal ideations, patients at risk of elopement, and patients engaged in self-injurious behavior. This failure has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility. Refer to A-115 (CoP for Patient Rights) and A-144.

3. The facility failed to ensure the hospital's performance improvement activities included the tracking of adverse patient events, conducting a root cause analysis of the adverse event, and implementing preventive action for P1, P2 and P4. The facility's failure affected the ability of the hospital to appropriately identify patients with suicidal ideations, elopement risk and self-injurious behavior. This failure has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility. Refer to A-263 (CoP for Quality Assurance Performance Improvement) and A-286.

4. The facility failed to ensure nursing personnel assigned to provide care were trained on the facility's policy regarding monitoring of patients and supervised to ensure that facility staff provided the nursing care to meet the patient needs for one of six sampled patients, (P1), to prevent his/her suicide. The facility's failure to appropriately monitor P1 resulted in the death of the patient and has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility.

On 04/07/20 at 1:00 PM, an interview was conducted with the CNO and the Assistant Chief Nursing Officer (ACNO). The ACNO stated increased monitoring of patients was implemented on 03/24/20 in response to the facility's mitigation efforts related to COVID-19. ACNO stated patients were required to spend more time on the units and the CNO and ACNO directed facility staff to increase the visual checks of patients from every 15 minutes to every 10 minutes and document the visual checks on the "Patient Location/Activity Checklist". ACNO further stated he reviewed the recorded video surveillance of the 03/26/20 incident involving P1 and discovered facility staff did not conduct a visual check of P1 from 8:08 PM to 8:44 PM. The CNO and ACNO confirmed during the interview there were no changes made to how nursing staff were monitored after the suicide of P1 to ensure visual checks of patients were conducted every 10 minutes.

Interview on 04/07/20 at 4:30 PM, the CEO stated the facility's response to P1's suicide included immediately removing facility staff assigned to P1 from care and reporting the incident to Adult Protective Services (APS). The CEO further stated the facility staff involved in the incident were terminated from employment on 03/27/20. However, the CEO stated the facility had not implemented any additional monitoring of staff after the incident even though the facility had identified that the failure of facility staff to properly conduct visual checks of patients as the primary reason for P1's suicide.

During an interview on 04/09/20 at 11:15 AM, the CEO stated he does not review incident reports and only receives information if the incident was reported to APS. Refer to A-385 (CoP for Nursing Services) and A-395.

This deficiency was cited based on complaint # WV00024001.

Based on interview, record review, review of facility's document and review of facility's policy, the facility failed to meet the Condition of Participation (CoP) for Patient Rights. Specifically, the facility failed to ensure three of six sampled patients (P) (P1, P2, and P4) received care in a safe setting; the facility failed to implement preventive actions which resulted in P1's suicide death, the self-injurious behavior of P4 and P2's elopement from the secure, fenced facility's grounds.

The facility's failure identified an Immediate Jeopardy (IJ) (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death).

On 04/07/20 at 7:30 PM, the Chief Executive Officer (CEO) was notified that an Immediate Jeopardy existed at Patient Rights in Safe Setting (A-144). The facility failed to ensure that nursing personnel provided care according to the assessed needs for three of six sampled patients (P) (P1, P2, and P4) and that the patients received the care and services in a safe setting. Specifically, the facility failed to implement preventive actions and mechanisms which resulted in P1's death by suicide; the facility failed to implement one-to-one (1:1) supervision, in that P4 conducted self-injurious behaviors that required hospital admission and surgery to remove a metal wire from P4's arm; and failed to protect P2 when outside with facility staff in the facility's fenced area, was left unsupervised by the facility's staff, went over the fence and eloped from the facility's property.

The facility provided an acceptable plan for removal of the Immediate Jeopardy on 04/09/20 at 5:00 PM. The facility's plan for removal of the Immediate Jeopardy included the training and monitoring of the facility's staff to ensure appropriate levels of supervision were maintained, documented, and monitored by the Chief Nursing Officer (CNO) and the Quality Management Department of the hospital. The facility's removal plan further included the Medical Staff's reassessment of all patients receiving care in the facility to determine their risk of suicide and self-injurious behavior. In addition, the removal plan included the installation of a new fence in a courtyard of the facility to prevent elopement. The removal plan required the Quality Management Department of the facility to provide daily reports to the CEO of the facility and requires monthly reports to be provided to the Governing Body of the hospital.

The facility's removal plan was validated by surveyors while on-site and submitted on 04/09/20 at 5:25 PM. The facility's removal plan was approved on 04/09/20 at 5:27 PM, at which time the CEO and Medical Director were notified.


Findings include:

1. Review of the facility's policy titled, "Sentinel Event Management," dated 03/18/19 indicated, "Sharpe Hospital is committed to investigating and analyzing patient safety events to promote the development of corrective actions that provide effective and sustained system improvements that reduce risk and prevent patient harm ... to reduce the probability of future events ... safety events and their contributing factors and strategies for prevention. Patient safety event: an event, incident, or condition that could have resulted or did result in harm to a patient ... the result of a defective system ... a system breakdown ... or human error. A sentinel event: A patient safety event ... that results in death, permanent harm, or severe temporary harm ... suicide of any patient receiving care and services in a staffed around-the-clock care setting ... an elopement of a patient. Adverse Event: A safety event that results in harm to a patient ..."

Review of the facility's document titled, "Functional Job Description" signed by the CEO on 02/23/16 indicated that the CEO of the facility was responsible to, " ...ensure compliance with federal and state regulatory requirements including but limited to goals of patient care, safety, education ..."

During an interview on 04/07/20 at 4:30 PM, the CEO stated he does not review incident reports and only receives information if the incident was reported to Adult Protective Services (APS). In addition, the CEO stated his responsibilities include ensuring the facility is compliant with regulatory requirements as stated in his job description.

2. The facility failed to ensure visual checks were completed for P1 which resulted in P1's suicide death. The facility failed to ensure P2 received adequate supervision to prevent the elopement of P2 from the facility's secure fenced grounds while in the presence of the facility's Mental Health Specialist. The facility failed to prevent P4 from engaging in self-injurious behavior that required the surgical removal of mental wire from P4's arm, while on one-to-one (1:1) supervision. The facility's failure affected the ability of the hospital to appropriately identify patients with suicidal ideations, patients at risk of elopement, and patients engaged in self-injurious behavior. This failure has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility. Refer to A-144.

This deficiency was cited based on complaint # WV00024001.

Based on interview, record review, review of facility's documents and facility's policies, the facility failed to ensure three of six patients (P) (P1, P2, and P4) received care in a safe setting. Specifically, the facility failed to ensure visual checks were completed for P1 which resulted in P1's suicide death. The facility failed to ensure adequate supervision was provided to P2 which resulted in the elopement of P2 from the facility. While on one-to-one (1:1) supervision, the facility failed to prevent P4 from engaging in self-injurious behavior which resulted in the P4's hospital admission and surgery to remove the mental wire from her arm. This deficient practice has the potential to affect all patients receiving care in the facility.

Findings include:

1. Review of the facility's "incident report" dated 03/26/20 at 8:40 PM, revealed P1 was found in the his/her room and had committed suicide by hanging. According to the facility's "Root Cause Analysis" (RCA) of the incident on 3/26/20 at 8:44 PM, P1 was found hanging by the neck by a cloth threaded through the top of a closet door. The incident report investigation revealed "Patient Location/Activity Checklists" were documented to indicate facility staff had completed visual checks of P1 every 10 minutes as required by the facility's Assistant Chief Nursing Officer (ACNO) memorandum dated 03/24/20. The facility's investigation included review of the facility's recorded video surveillance, which revealed that facility staff did not conduct visual checks of the resident every 10 minutes to ensure P1 was safe. The recorded video surveillance indicated that the facility's staff failure to conduct visual checks from 8:08 PM to 8:44 PM, allowed P1 to be unsupervised for 36 minutes and was the primary reason P1 was able to commit suicide. The recorded video surveillance indicated that P1 was observed by Licensed Practical Nurse (LPN) 1 and Registered Nurse (RN)1 at 8:08 PM, when the LPN1 and RN1 entered P1's room and observed P1 in the shower. At 08:13 PM, the Health Service Worker opened P1's bedroom door and was in the room approximately three seconds. At 8:31 PM, Health Service Worker walked past P1's room without entering P1's bedroom. It was not until 8:44 PM, that LPN1 and RN1 entered P1's bedroom and found that P1 had committed suicide. The "RCA" further indicated that P1's "Patient Location/Activity Checklists" dated 03/26/20 from 8:08 PM to 08:44 PM documented that facility staff performed hall checks every 10 minutes as required by the Assistant Chief Nursing Officer (ACNO) memorandum dated 03/24/20 which indicated, "The hall walk (visual checks) should be taking place on a 10-minute interval to ensure patients are safe in their rooms."

Review of P1's "Face Sheet," located in the electronic health record (EHR), revealed P1 was admitted to the facility from the community on 03/11/20 due to a deterioration in psychiatric stability. Review of P1's "M and M Conference" document dated 03/27/20 by the Deputy Medical Director indicated the patient was discharged from another facility in February 2020 and "demonstrated a number of maladaptive and antisocial behaviors." The document further revealed P1 was "noncompliant with taking medications and suffered from hallucinations." In addition, P1's "M and M Conference" document revealed, "The patient displayed aggressive behavior towards facility staff and other patients on 03/12/20, 03/16/20, 03/19/20, and 03/23/20." Further review of the "M and M Conference" document indicated P1 was "noncompliant with labs, physical exams, vitals, medications, groups, and PPD [purified protein derivative]."The document indicated that on 03/17/20, treatment team meeting and the notes indicated, "denied suicidal or homicidal ideations."

2. Review of a facility "incident report" dated 3/25/20 at 11:35 AM, revealed P2 eloped from the facility's fenced outdoor area of the facility while in the presence of a Mental Health Therapist (MHT). P2's elopement was reported to local law enforcement at 11:34 AM and the patient was returned to the facility by police officials at 12:57 PM, which was 1 hour and 22 minutes after the elopement from the facility. Review of the recorded video surveillance and review of the "RCA" of the incident indicated that the MHT was distracted by another patient and P2 "went over the fence." In addition, the "RCA" indicated the patient to staff ratio was not followed. The "RCA" indicated, "Staff to patient ration requires two staff members to be present for two to seven patients." The document further indicated, "The Mental Health Therapist did not have a radio to alert the facility of the elopement."

Review of P2's "Face Sheet," located in the his/her EHR revealed P2 was admitted to the facility on 02/07/20 with and admitting diagnoses of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Methamphetamine Dependence, and Bipolar Disorder.

3. Review of the facility's policy titled, "Patient Care, Levels of Observation" dated 07/15/19 indicated, "All patients are placed on an observation level based on clinical assessment of the patient's needs, risk conditions and behavior ...2. One-to-one Observation (1:1) ...E. A patient on this level of observation must be within arm's length of the assigned staff member at all times ..."

P4's "Face Sheet," located in the EHR indicated he/she was admitted to the facility on 01/21/20 with diagnoses including bipolar disorder, post-traumatic stress disorder and intentional self-harm/injurious behavior.

Review of P4's "Nursing Progress Notes" dated 01/30/20 indicated, "_____(P4) has threatened to harm himself/herself when boundaries are set. His/her continued care observation remains to ensure his/her safety at this time."

Review of P4's "Nursing Progress Notes" dated 02/20/20 indicated, "_____(P4) will need to have a facility that is able to ensure the level of safety he/she requires, he/she is currently on 1:1 due to self-injurious behaviors. Staff will provide 1:1 observation to ensure he/she is within a safe environment and to redirect him/her from self-injurious behaviors."

Review of an "Incident Report" dated 03/08/20 at 09:45 AM, revealed P4 harmed himself/herself while on 1:1 observation status. The incident report reflected that P4 "informed a nurse on duty that he/she had shoved a small piece of wire metal from her bra clasp into his/her right arm." The incident report indicated, "Pt [patient] sent to hospital, x-rays showed a foreign object in his/her right arm ... we are to call tomorrow to set up surgery date to remove." Documentation on the back page of the incident report indicated, "_____(P4) inserted an object into his/her forearm while on 1:1 status."

Interview on 04/07/20 at 2:15 PM, the Registered Nurse Chief Quality Officer (RNCQO) stated she completed the investigations related to P1's suicide, P2's elopement, and P4's incidents of self-injurious behavior. RNCQO stated the facility has not addressed increasing levels of supervision of patients as a result of the investigated incidents. RNCQO further stated the facility had not completed a suicide risk assessment on any of the patients in the facility, had not assessed P2 as an elopement risk prior to the 03/25/20 incident, and had not assessed any patients for increased risks of self-injurious behavior.

During an interview on 04/08/20 at 9:30 AM, the RNCQO stated, "I don't know how he/she removed a piece of metal and impeded it in his/her arm while under 1:1 observation." (Referring to P4's incident on 03/08/20). The RNCQO stated, "I'm not sure who was observing him/her at the time of the incident. The incident should have been assigned for further review according to our sentinel event policy. It should not have happened while on 1:1 observation."

Review of an "Incident Report," dated 03/26/20 at 11:35 AM, revealed P4 used a metal object to cause two lacerations to his/her left forearm and one laceration to his/her right forearm while on 1:1 observation. The lacerations required medical intervention. The incident report reflected, "____(P4) reported to the nurse ... both of his/her arms were cut. He/she reported that he/she cut himself/herself with a small piece of metal he/she found on the floor. He/she was on 1:1 status already but was able to harm himself/herself with metal found on the floor. He/she remains on 1:1 status."

During an interview on 04/08/20 at 05:00 PM, the RNCQO stated, "The incident that occurred on 03/26/20 was not investigated. We assigned it for further information needed but it was missed. It should have had further review."

Review of an "Incident Report," dated 04/06/20 at 11:30 AM, revealed P4 pierced his/her left eyebrow with the tooth of a comb while on 1:1 observation. The incident report reflected, "It was noted that patient had what appeared to be a new piercing on the left outer eyebrow." The back page of the incident report reflected an ACA was ordered for additional follow-up.

Review of the facility's policy titled, "Statement of Rights of Patients From Mental Health Code of West Virginia (Chapter 27, Section 5, Article 9)" dated 09/2004 indicated, "Each patient of a mental health facility receiving services from there shall receive care and treatment that is suited to his/her needs and administered in a skillful, safe, and humane manner with full respect for his/her dignity and personal integrity."

This deficiency was cited based on complaint # WV00024001.

Based on interview, record review, review of the facility's documents and review of the facility's policies, the facility failed to meet the Condition of Participation (CoP) for Quality Assessment and Performance Improvement (QAPI) when the facility failed to ensure the performance improvement activities of the hospital, tracked adverse patient events, analyzed the cause of the adverse event, and implemented preventive action for three of six sampled patients, (Patient (P)1, P2 and P4). The cumulative effect of this deficient practice to conduct performance improvement activity identified an Immediate Jeopardy (IJ) (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death).

On 04/07/20 at 7:30 PM, the Chief Executive Officer (CEO) was notified that an Immediate Jeopardy existed at Patient Safety (A-286). Specifically, the facility failed to track and analyze the cause of the adverse events and implement preventive actions after P1's suicide death; after P4's self-injurious behaviors that required hospital admission and surgery to remove a foreign body from P4's arm; and after P2 eloped from the facility's fenced area while in the presence of the Mental Health Therapist.

The facility provided an acceptable plan for removal of the Immediate Jeopardy on 04/09/20 at 5:00 PM. The facility's plan for removal of the Immediate Jeopardy required the facility's Quality Management Department to provide daily reports to the CEO of the facility and required monthly reports to be provided to the Governing Body of the hospital.

The facility's plan for removal was validated by surveyors while on-site and submitted on 04/09/20 at 5:25 PM. The facility's plan for removal was approved on 04/09/20 at 5:27 PM, at which time the CEO and Medical Director were notified.


Findings include:

1. The facility failed to ensure three of six patients (P) (P1, P2, and P4) received care in a safe setting. Specifically, the facility failed to ensure visual checks were completed for P1 which resulted in P1's suicide death. The facility failed to ensure adequate supervision was provided to P2 which resulted in the elopement of P2 from the facility. While on one-to-one (1:1) supervision, the facility failed to prevent P4 from engaging in self-injurious behavior which resulted in a hospitalization of P4's for the surgical removal of metal wire in the patient's arm. Refer to A-144.

2. The facility failed to investigate an incident report with adverse patient outcome to determine the root cause of the incident. In addition, the facility failed to analyze the results of adverse patient events and implement preventive action for three of six sampled patients, (Patient (P)1, P2 and P4) to ensure their safety and that services were provided to meet their assessed needs. The facility's failure affected the ability of the hospital to appropriately identify patients with suicidal ideations, elopement risk and self-injurious behaviors. This failure has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility. Refer to A-286.

This deficiency was cited based on complaint # WV00024001.

Based on interview, record review, review of the facility's documents and review of the facility's policies, the facility failed to ensure the performance improvement activities of the hospital included the tracking of adverse patient events, conducting the Root Cause Analysis (RCA) of the adverse event, and implemented preventive actions for three of six sampled patients, (Patient (P)1, P2 and P4). The facility's failure affected the ability of the hospital to appropriately identify patients with suicidal ideations, elopement risk and self-injurious behavior. This failure has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility.

Findings include:

1. Review of the facility's policy titled, "Sentinel Event Management," dated 03/18/19 indicated, "Sharpe Hospital is committed to investigating and analyzing patient safety events to promote the development of corrective actions that provide effective and sustained system improvements that reduce risk and prevent patient harm ... to reduce the probability of future events ... safety events and their contributing factors and strategies for prevention. Patient safety event: an event, incident, or condition that could have resulted or did result in harm to a patient ... the result of a defective system ... a system breakdown ... or human error. A sentinel event: A patient safety event ... that results in death, permanent harm, or severe temporary harm ... suicide of any patient receiving care and services in a staffed around-the-clock care setting ... an elopement of a patient. Adverse Event: A safety event that results in harm to a patient. Apparent Cause Analysis (ACA) is used to determine cause of patient safety events. Root Cause Analysis (RCA) ... a fact-based analysis that identifies the corrective actions that, if taken, will prevent recurrence of this consequence and related consequences. The comprehensive systemic analysis must: clearly show the cause-and-effect relationship ... human errors ... violations of procedure ... failure to act when there is a preexisting duty to act ... the comprehensive analysis will include an action plan ... the action plan will be approved by the CEO [Chief Executive Officer] or designated member ... the ACA report will identify breakdowns in behavior, process ... with a description of why each breakdown occurred. The compliance department will report the analysis to the CQI [Continued Quality Improvement] Committee each month ... the department manager/supervisor will be required to thoroughly analyze the event including relevant policies and processes ... and statements from the involved staff."

Review of the facility's policy titled, "Quality Assurance Performance Improvement (QAPI) and Patient Safety Plan" dated 01/30/20 indicated, " ...establishes a collaborative, planned, systematic, and organization-wide approach to measure, assess, and improve the quality of care and patient outcomes while continuing to identify and reduce safety risks to patients." In addition, the policy indicated, the facility's "intent and objective is to use data collection and analysis for identifying systems and processes that may need changed for improving quality of care and services, improving staff performance, and improving patient safety by reducing the risk of adverse events."

1. Review of the facility's policy titled, "Patient Location/Activity" dated 03/07/19 indicated, "Nursing staff will conduct a 15-minute scheduled count of patients assigned to his/her unit throughout their shift ..."

Review of the Assistant Chief Nursing Officer (ACNO) memorandum dated 03/24/20 indicated, "The hall walk (visual checks) should be taking place on a 10-minute interval to ensure patients are safe in their rooms." The ACNO directed facility staff that these checks were required to be documented on a log and authenticated by nursing staff on each unit.

Review of P1's "incident report" dated 03/26/20 at 8:44 PM revealed P1 was found in his/her room and had committed suicide by hanging. According to the "Root Cause Analysis" (RCA) indicated P1 was found hanging by the neck by a cloth threaded through the top of a closet door. Review of the facility's recorded video surveillance revealed facility staff did not conduct visual checks of the resident as required by the ACNO's 03/24/20 memorandum to ensure P1's safety. Review of the "incident report investigation" and "Patient Location/Activity Checklists" indicated facility staff had documented that they had completed visual checks of P1 as required every 10 minutes. However, the RCA indicated that when the recorded video surveillance tape was compared to the "Patient Location/Activity Checklists" it revealed that facility staff did not conduct visual checks from 8:08 PM to 8:44 PM, leaving the patient unsupervised for 36 minutes.

On 04/07/20 at 1:00 PM, an interview was conducted with the Chief Nursing Officer (CNO) and the Assistant Chief Nursing Officer (ACNO). The ACNO stated increased monitoring of patients was implemented on 03/24/20 in response to the facility's mitigation efforts related to COVID-19. ACNO stated patients were required to spend more time on the units and the CNO and ACNO directed facility staff to increase the visual checks of patients from every 15 minutes to every 10 minutes and document the visual checks on the "Patient Location/Activity Checklist". ACNO further stated he reviewed the recorded video surveillance for the 03/26/20 incident involving P1 and discovered facility staff did not conduct a visual check of P1 from 8:08 PM to 8:44 PM. The CNO stated there was no increased monitoring of facility staff after P1's suicide to ensure visual checks of patients were completed as directed by the ACNO's 03/24/20 memorandum and that the facility did not identify any system failures after P1's suicide incident.

2. Review of a facility "incident report" dated 3/25/20 at 11:35 AM, revealed P2 eloped from the facility's secured, fenced outdoor area of the facility while in the presence of a Mental Health Therapist (MHT). P2's elopement was reported to local law enforcement at 11:34 AM and the patient was returned to the facility by police officials at 12:57 PM, which was 1 hour and 22 minutes after the elopement from the facility. Review of the recorded video surveillance and review of the "RCA" of the incident indicated that the MHT was distracted by another patient and P2 "went over the fence." In addition, the "RCA" indicated the patient to staff ratio was not followed, in that, "Staff to patient ration requires two staff members to be present for two to seven patients." The "RCA" further indicated, "The Mental Health Therapist did not have a radio to alert the facility of the elopement."

Review of P2's "Face Sheet," located in the his/her EHR revealed P2 was admitted to the facility on 02/07/20 with and admitting diagnoses of Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Methamphetamine Dependence, and Bipolar Disorder.

3. Review of an "Incident Report," dated 03/08/20 at 09:45 AM, revealed P4 harmed himself/herself while on one-to-one (1:1) observation status. The "incident report" reflected that P4 informed a nurse on duty that he/she had shoved a small piece of metal wire into his/her right arm. The "incident report" indicated, "Pt [patient] sent to hospital, x-rays showed a foreign object in his/her right arm ... we are to call tomorrow to set up surgery date to remove."

During an interview on 04/08/20 at 9:30 AM, the Registered Nurse-Chief Quality Officer (RNCQO) stated, "The incident should have been assigned for further review according to our sentinel event policy. It should not have happened while on 1:1 observation."

Review of an "Incident Report," dated 03/26/20 at 11:35 AM, revealed, "[P4] used a metal object to cause two lacerations to his/her left forearm and one laceration to his/her right forearm while on 1:1 observation. The lacerations required medical intervention."

During an interview on 04/08/20 at 5:00 PM, the RNCQO stated, "The incident on 03/26/20 was assigned for Apparent Cause Analysis (ACA) for additional follow-up but it wasn't done. We missed it."

On 04/09/20 the RNCQO provided an "ACA" dated 04/08/20 which indicated, "Patient was able to remove eyelet from his/her shoe and obtain a piece of metal on the unit while on 1:1 observation. Patient was able to inflict self-injurious behaviors while on 1:1." The RNCQO stated that the Levels of Observation policy indicated that staff must be within arm's length with nothing in between staff member and patient. The RNCQO stated that the facility's contraband and search policy was not followed in that the metal like item was not logged into the security log and the incident was not reported to Safety and Security Director. The RNCQO stated that the Licensed Practical Nurse (LPN) threw the metal item into the trash in the treatment room and the piece of metal was removed from patient's possession. The patient was sent to the in-house medical clinic for sutures and dressings.

Review of an "Incident Report," dated 04/06/20 at 11:30 AM, revealed P4 pierced his/her left eyebrow with the tooth of a comb while on 1:1 observation. The back page of the incident report reflected an ACA was ordered for additional follow-up.

Review of the "ACA" dated 04/06/20 indicated, "Patient presented with an entry and exit wound above and below the outer edge of his/her left eyebrow. He/she was questioned by the RN [Registered Nurse] and stated he/she felt like harming himself/herself so he/she used a piece of comb to pierce his/her eyebrow but could not tell the RN when this occurred. Patient was on 1:1 observation ..."

Interview on 04/07/20 at 4:30 PM, the CEO stated that the facility's response to P1's suicide included the immediate removal of the facility staff assigned to P1 from providing care to any patient and reporting the incident to Adult Protective Services (APS). The CEO further stated the facility staff involved in the incident was terminated from employment on 03/27/20. However, the CEO stated the facility had not implemented any additional monitoring of staff after the incident even though the facility had identified that facility staff did conduct visual checks of patients as directed by the facility's policy and at the frequency as indicated in the Assistant Chief Nursing Officer (ACNO) memorandum dated 03/24/20 which indicated, "The hall walk (visual checks) should be taking place on a 10-minute interval to ensure patients are safe in their rooms."

During an interview on 04/07/20 at 2:15 PM, the RNCQO stated he/she investigated P1's suicide and was responsible for completing the RCA of the 03/26/20 incident. RNCQO stated the facility created an "Action Plan" to address re-educating nursing staff on conducting "hall walks" more frequently which would increase staff presence on the units of the facility. However, the facility had not addressed increased supervision and monitoring of the facility staff to ensure "hall walks" were completed as directed according to the 3/24/20 memorandum. RNCQO further stated the facility had identified 18 patients in the facility who were at an increased risk of suicide due to needing "Unsupervised Medical Equipment", such as oxygen tubing. However, the RNCQO stated the facility had not completed a suicide risk assessment on any of the patients in the facility and had not assessed any patients for increased risks of self-injurious behavior.

Interview on 04/07/20 at 3:00 PM, the Medical Director stated that he was aware the facility's RCA and had reviewed the recorded video surveillance of P1's suicide on 3/26/20 which revealed that facility staff failed to properly conduct visual checks of P1. In addition, the Medical Director stated that after this incident, the facility should have implemented measures to monitor staff's compliance with the timeliness of visual checks of patients. The Medical Director further stated he was aware that the patients in the facility had not been reassessed after the 03/26/20 incident and could not confirm if all the patients in the facility had be assessed for self-injurious behavior or suicidal risks.

During an interview on 04/09/20 at 9:30 AM, the RNCQO stated, "I have never considered tracking the person assigned to do 1:1 observation during these incidents. The incident form does not have a place to document the staff member who was responsible for the 1:1 observation. The ACA form does not address who was assigned 1:1 observation of the patient at the time of the incident."

During an interview on 04/09/20 at 1:00 PM, the CEO stated he does not review incidents reports and only receives information if the incident was reported to Adult Protective Services (APS). The CEO stated, "Anyone can complete the incident report. The nurse manager or supervisor on duty completes the back portion of the report. The report then goes to the compliance committee and they decide if more information is needed. An ACA meeting is then scheduled, and I attend. If the incident is referred to APS they have seven days to complete the investigation. The staff member is removed from patient care if an APS referral is made. There is always an administrator on call. I was on call on 03/08/20 and 03/26/20 when P4's incident occurred. They didn't tell me she was on 1:1 observation when the incidents occurred. This is information should be shared with every administrator on call. I agree a reasonable person would question how the incidents continued to occur while on 1:1 observation."

Interview on 04/09/20 at 3:00 PM, the Safety Officer stated the Safety Committee of the facility does not currently track or trend any data related incidents of intentional self-injury. The Safety Officer further stated the Quality Management Department and the hospital administration would not be informed of concerns related to injuries that occurred to patient on increased levels of supervision such as 1:1 supervision. In addition, the Safety Officer indicated data for March 2020 had not been reported to the Quality Management Department or the hospital administration to determine if changes to patient levels of supervision needed to be changed.

This deficiency was cited based on complaint # WV00024001.

Based on record review, review of facility's document, and interview, it was determined the hospital failed to meet the Condition of Participation (CoP) for Nursing Services when the facility failed to ensure nursing personnel were monitored and supervised to evaluate the needs of one of six sampled patients (P) (P1) to prevent suicide. This deficient practice has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patients receiving care in the facility.

The facility's failure identified an Immediate Jeopardy (IJ) (represents a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death).

On 04/07/20 at 7:30 PM, the Chief Executive Officer (CEO) was notified that an Immediate Jeopardy existed at Registered Nurse (RN) Supervision of Nursing Care (A-395). The facility failed to ensure that nursing personnel provided care according to the assessed needs for one of six sampled patients (P) (P1) and that patients received the care and services in a safe setting. Specifically, the facility failed to implement preventive actions which resulted in P1's suicide death.

The facility provided an acceptable plan for removal of the Immediate Jeopardy on 04/09/20 at 5:00 PM. The facility's plan for removal of the Immediate Jeopardy included the training and monitoring of the facility's staff to ensure appropriate levels of supervision were maintained, documented, and monitored by the Chief Nursing Officer (CNO) and the Quality Management Department of the hospital. The facility's removal plan further included the Medical Staff's reassessment of all patients receiving care in the facility to determine their risk of suicide and self-injurious behavior.

The facility's plan for removal was validated by surveyors while on-site and submitted on 04/09/20 at 5:25 PM. The facility's plan for removal was approved on 04/09/20 at 5:27 PM, at which time the CEO and Medical Director were notified.

Findings include:

The facility failed to ensure nursing personnel were monitored and supervised to evaluate the care of one of six sampled patients (P) (P1) to prevent suicide. Nursing personnel failed to complete required visual checks as required by the facility's Assistant Chief Nursing Officer (ACNO) memorandum dated 03/24/20 which indicated, "The hall walk (visual checks) should be taking place on a 10-minute interval to ensure patients are safe in their rooms." Refer to A-395.

This deficiency was cited based on complaint # WV00024001.

Based on record review, interview, review of the facility's documents and policies, the facility failed to assure nursing personnel assigned to provide patient care were monitored and supervised for one of six sampled patients (P) (P1) to prevent suicide. The facility's failure to appropriately monitor resulted in P1's suicide death and has the potential to negatively affect the hospital's ability to safely provide care to patients and meet the psychiatric needs of all patient receiving care in the facility.

Findings include:

Review of the facility's "incident report" dated 03/26/20 revealed P1 was found in his/her room and had committed suicide by hanging. According to the "Root Cause Analysis" (RCA) of the incident on 3/26/20 at 8:44 PM, P1 was found hanging by the neck by a cloth threaded through the top of a closet door. The facility's "investigation documents" revealed that the facility's recorded video surveillance had been reviewed and that facility staff did not conduct visual checks of the resident as required to ensure P1 was safe. In addition, the "incident report investigation" revealed "Patient Location/Activity Checklists" were documented to indicate facility staff had completed visual checks of P1 as required every 10 minutes. The "RCA" revealed the facility staff failed to conduct visual checks from 8:08 PM to 8:44 PM, leaving the patient unsupervised for 36 minutes, which was the primary reason P1 was able to commit suicide.

Review of the facility's policy titled, "Patient Location/Activity" dated 03/07/19 indicated, "Nursing staff will conduct a 15-minute scheduled count of patients assigned to his/her unit throughout their shift. In addition to the 15-minute scheduled count of patients, a door safety check will also be completed."

Review of the memorandum from the Assistant Chief Nursing Officer (ACNO) dated 03/24/20, revealed the ACNO directed facility staff to conduct visual checks called, "hall walks" for all patients every 10 minutes in response to mitigation efforts related to COVID-19. These checks were required to be documented on a log and the authenticated by nursing staff on each unit. The memorandum indicated, "The hall walk should be taking place on a 10-minute interval to ensure patients are safe in their rooms."

During an interview on 04/07/20 at 1:00 PM with the Chief Nursing Officer (CNO) and the ACNO, the ACNO stated that he/she had reviewed the facility's recorded video surveillance of the 03/26/20 incident involving P1 and discovered facility staff did not conduct a visual check of P1 from 8:08 PM to 8:44 PM. The CNO stated there was no increased monitoring of facility staff after P1's suicide to ensure visual checks of patients were completed.

This deficiency was cited based on complaint # WV00024001.