HospitalInspections.org

Based on medical record review, policy review and staff interviews, it was determined the hospital failed to ensure that an Adult Protective Order was filed on one (1) out of two (2) patients, Patient #11, who lacked capacity and had sexual intercourse on Unit Four (4) West. This failure has the potential for all patients, who lack capactiy and are admitted to the unit, to be at risk for sexual contact.

1. Review of the medical record for Patient #11 revealed the patient was admitted to Four (4) West on 11/15/18, with a diagnosis of Schizoaffective Disorder, and lacks capacity. A nursing note on 11/17/18 at 10:44 p.m. states in part: "During medication pass heard someone yelling for me and I put my cart away and saw staff and patients around room 412. Staff told me the patients were having sex, Patient #12. The patients were immediately separated and the male patient was taken away to his room. Patient #11's health surrogate was notified, but no documentation of notification of the physician was documented and no Adult Protective Order was filed.

2. Review of the policy titled Reporting of Abuse, last revision date 06/17, states in part: "Any known or suspected abuse/neglect of an incapacitated adult will be reported to the Department of Health and Human Resources Adult Protective Services, the WV State Police and the Prosecuting Attorny for the county where abuse occured...will contact the physician, the Program Manager and/or the Chief Nursing Officer.

3. An interview was conducted on 12/12/18 at 11:30 a.m. with the Interim Director of Nursing. When asked to review the chart for physician notification and an Adult Protective Order filed, she stated in part: "I do not see when the physician was notified about the sexual encounter and I do not see an Adult Protective Order.

4. An interview was conducted on 12/12/18 at 12:45 p.m. with the Nurse Manager of Four (4) West and she concurred with the above findings.

The Director of Nursing failed to be responsible to ensure a Registered Nurse (RN) is on all patient units twenty-four (24) hours a day, see tag A 0392. The hospital failed to ensure a RN supervised all patients in the hospital, see Tag A 0395.

Based on document review, schedule review, policy review and staff interviews, it was determined the hospital failed to ensure three (3) out of six (6) patient care units, Unit Two (2) North, One (1) East and Three (3) East, were staffed with a Registered Nurse (RN) twenty-four (24) hours a day, when patients are admitted to the unit. This failure has the potential for all patients who are admitted to the units to not have an RN to immediately care for them during an emergency.

1. Review of the staffing matrix, last review date of 1/18/18, revealed that One (1) East requires one (1) RN and one Mental Health Technician (MHT) for one (1) through ten (10) patients. Two (2) North requires one (1) RN and one (1) MHT for dayshift and nightshift for one (1) through eight (8) patients. Evening shift requires one (1) RN and MHT for one (1) through six (6) patients and one (1) RN and two (2) MHT's for seven (7) through eight (8) patients. Unit Three (3) East requires one (1) RN and one (1) MHT for dayshift and nightshift for one (1) through ten (10) patients. Evening shift requires one (1) RN and one (1) MHT for one (1) through ten (10) patients and one (1) RN and two (2) MHT's for eleven (11) through twelve (12) patients.

2. Review of staffing schedules from June 2018 through present revealed staffing was completed using the hospitals matrix system.

3. Review of the policy titled Staffing/Supervision, last review date of 07/18, states in part: "The Nursing Supervisor and/or any additional Supervisory staff conduct frequent rounds of all units and perform the following task: 1. Ensure adequate supervision and staffing; providing breaks and fill-in as needed."

4. An interview was conducted on 12/10/18 at 1:10 p.m. with RN #1. When asked how the unit is covered if she goes to lunch, pharmacy or anytime she needs to leave the unit, she stated in part: "When I go to lunch I call the Nursing Supervisor and they will send someone to the unit while I have lunch. If I go to a code though, I'm the only nurse scheduled and I go to the code and the techs watch the floor until I get back. I don't leave the floor any other time." When asked if the Supervisor would come to the unit to cover, she stated in part: "Well, sometimes for lunch but not for the code. The Supervisor is in the code too."

5. An interview was conducted on 12/11/18 at 2:30 p.m. with MHT #1. When asked how many RN's work the unit with him, what the process is to cover the RN when they would need to leave the unit and for what reasons the RN may leave the unit, he stated in part: "Well, the nurse leaves the unit for lunch, sometimes to go to the pharmacy and for codes. They call the Supervisor and they sometimes send a tech to help cover the unit while they are gone." When asked if they ever send an RN he stated in part: "Nope, sometimes they don't even send a tech if the therapist is on the unit and she's too busy doing therapy to help us."

6. An interview was conducted on 12/11/18 at 3:30 p.m. with Nursing Supervisor #1. When asked how she staffs the nursing units that only have one RN scheduled, during lunch or if they need to leave to go to the pharmacy, she stated in part: "Well, I have some really strong techs on certain floors so if the nurse goes to lunch or needs to go to the pharmacy, I will send one of the stronger techs to the unit to help cover lunches." When asked if she ever sends another RN to the unit for coverage she stated in part: "I don't have another one to send. The units who have two (2) RN's need those because of the acuity of their patients."

7. An interview was conducted on 12/11/18 at 4:45 p.m. with the Director of Nursing. When asked if she realized Unit One (1) East, Two (2) North and Three (3) East were unsupervised by a RN during their lunch breaks, codes and if they need to go to the pharmacy to pick-up their patient medications, she concurred with the above finding.

Based on document review, schedule review, policy review and staff interviews, it was determined the Director of Nursing failed to ensure supervision of care on three (3) out of six (6) patient care units, Unit Two (2) North, One (1) East and Three (3) East). This failure has the potential for all patients who are admitted to the units, to not have immediate nursing care, when needed for an emergency.

1. Review of the staffing matrix, last review date 1/18/18, revealed that One (1) East requires one (1) Registered Nurse (RN) and one Mental Health Technician (MHT) for one (1) through ten (10) patients. Two (2) North requires one (1) RN and one (1) MHT for dayshift and nightshift for one (1) through eight (8) patients. Evening shift requires one (1) RN and one (1) MHT for one (1) through six (6) patients and one (1) RN and two (2) MHT's for seven (7) through eight (8) patients. Unit Three (3) East requires one (1) RN and one (1) MHT for dayshift and nightshift for one (1) through ten (10) patients. Evening shift requires one (1) RN and one (1) MHT for one (1) through ten (10) patients and one (1) RN and two (2) MHT's for eleven (11) through twelve (12) patients.

2. Review of staffing schedules from June 2018 through present revealed staffing was completed using the hospitals matrix system.

3. Review of the policy titled Staffing/Supervision, last review date 07/18, states in part: "The Nursing Supervisor and/or any additional Supervisory staff conduct frequent rounds of all units and perform the following task: 1. Ensure adequate supervision and staffing; providing breaks and fill-in as needed."

4. An interview was conducted on 12/10/18 at 1:10 p.m. with RN #1. When asked how the unit is covered if she goes to lunch, pharmacy or anytime she needs to leave the unit she stated in part: "When I go to lunch I call the Nursing Supervisor and they will send someone to the unit while I have lunch. If I go to a code though, I'm the only nurse scheduled and I go to the code and the techs watch the floor until I get back. I don't leave the floor any other time." When asked if the Supervisor would come to the unit to cover she stated in part "Well, sometimes for lunch but not for the code. The supervisor is in the code too."

5. An interview was conducted on 12/11/18 at 2:30 p.m. with MHT #1. When asked how many RN's work the unit with him, the process to cover the RN when they would need to leave the unit and for what reasons the RN may leave the unit, he stated in part: "Well, the nurse leaves the unit for lunch, sometimes to go to the pharmacy and for codes. They call the Supervisor and they sometimes send a tech to help cover the unit while they are gone." When asked if they ever send an RN he stated in part: "Nope, sometimes they don't even send a tech if the therapist is on the unit and she's too busy doing therapy to help us."

6. An interview was conducted on 12/11/18 at 3:30 p.m. with Nursing Supervisor #1. When asked how she staffs the nursing units that only have one RN scheduled during lunch or if they need to leave to go to the pharmacy, she stated in part: "Well, I have some really strong techs on certain floors so if the nurse goes to lunch or needs to go to the pharmacy, I will send one of the stronger techs to the unit to help cover lunches." When asked if she ever sends another RN to the unit for coverage, she stated in part: "I don't have another one to send. The units who have two RN's need those because of the acuity of their patients."

7. An interview was conducted on 12/11/18 at 4:45 p.m. with the Director of Nursing. When asked if she realized Unit One (1) East, Two (2) North and Three (3) East were unsupervised by a RN during their lunch breaks, codes and when they need to go to the pharmacy to pick-up their patient medications, she concurred with the above findings.

Based on observation and interview, the agency failed to ensure the Information Security Department provided the State surveyors access to the Electronic Health Records (EHR) in a timely fashion as requested. This has the potential to negatively impact all patient care by impeding the survey process by unnecessarily delaying access to the medical record.

Findings include:

1. The facility uses an electronic charting system for all treatment modalities. In order to safeguard access to the EHR, each person is issued their own authentic user name and password.

2. The State surveyor entered the agency 12/10/18 at 8:40 a.m. and immediately requested access to the EHR. Access codes were given at approximately 12:00 p.m. and they failed to allow access to the EHR.

3. An interview was conducted on 12/10/18 at 10:30 a.m. with the Director of Risk Management and when asked when medical access would be granted she stated in part: "We are waiting on you to give us your identifier list so that we can print your medical records." When asked if they were having problems with their Internet access or Internet she stated in part: "No, that is our process. We don't give you access to the electronic records and never have." I then explained that I have always had electronic access to the medical records on previous surveys and that I expect the process to be followed on this survey.

4. An interview was conducted on 12/10/18 at approximately 10:40 a.m. with the Chief Financial Officer. When asked when access to the electronic medical record would be given because I needed access to a death record he stated in part: "Well, we wait for you to give us your identifier list and we print your medical records. We don't give you computer access. I explained that when a facility has electronic medical records, we as part of the survey process, expect access to the records. I explained that by giving them a list of the patients we would like to look at would be giving them an identifier list and as a part of the survey process, that is not acceptable. I emailed a copy of the Social Security Act with access for him to review and forward to the Corporate Office for access. Access to Electronic Medical Records with a password was given to the surveyors at 12:30 p.m.

5. An interview was conducted on 12/10/18 at approximately 10:45 a.m. with the Chief Financial Officer and although he was working on our access to medical records, he concurred with the above findings that access to electronic medical records had been denied.