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Based on document review and staff interview, it was determined the facility failed to review grievances seven (7) days a week. This failure has the potential to place patients in harm if the grievance is related to abuse or neglect.

Findings include:

A review of faclity policy, titled "Handling of Patient Complaint/Grievances", effective 02/06/23, states in pertinent part: "Procedure ... 2 ... a) Patients are provided with grievance forms and helped to complete if needed. b) The patients place the completed grievance form in a locked box located in each patient unit. c) The nurse manager or designee will retrieve the grievance form from the locked box on each unit and will date and timestamp the grievance form and notify the patient that the grievance has been received. The nurse manager or designee will work with a patient's treatment team to resolve the grievance ..."

Upon leaving the exit conference on 06/07/23 at approximately 2:45 p.m., the Chief Executive Officer explained grievances are not obtained out of the grievance box seven (7) days a week due to the patient advocates witnessing the removal, and they are only present Monday through Friday."

Based on medical record review, document review, and staff interview, it was determined the facility failed to allow patients to have the right to refuse medications in three (3) out of ten (10) patients reviewed, patients #3, 7, and 9, by concealing the medications in food/beverage. This failure has the potential to cause harm to all patients receiving care at the facility.

Findings include:

A medical record review was conducted of patient #3. The patient was admitted to the facility on 05/05/23 with a diagnosis of Bipolar I Disorder. The patient was found to lack capacity. On 05/07/23 at 2:00 p.m. an "Independent Evaluation Need to Treat/Tx Without Consent" note by the Assistant Medical Director (ADM) states in part, "The patient refuses medication due to their illness and there is a statutory Authority for treatment." The patient's medication order states, "Lithobid tab SA [short-acting] 300 mg [milligram]; 900 mg pill daily at 1700 [5:00 p.m.] for mood; please offer tablet to pt [patient] first, if [patient #3] declines please conceal in food or drink for administration. HCS [Health Care Surrogate] has consented to conceal this medication in food/drink."

A medical record review was conducted for patient #7. The patient was admitted to the facility on 09/10/21 with a diagnosis of Bipolar I Disorder. The patient was found to lack capacity. On 10/06/21 at 10:13 a.m. an "Independent Evaluation Need to Treat/Tx Without Consent" note by physician #2 states in part, "The patient refuses medication due to their illness and there is a statutory Authority for treatment." The patient's medication order states, "Lithium Carbonate Cap, Oral 600 mg daily 1700 [5:00 p.m.] Indication: mood stabilization. Dissolve in food without patient's knowledge if [patient #1] refuses (guardian gave consent)."

A medical record review was conducted for patient #9. The patient was admitted to the facility on 12/02/20 with a diagnosis of schizoaffective disorder. The patient was found to lack capacity. On 12/03/20 at 1:38 p.m. an "Independent Evaluation Need to Treat/Tx Without Consent" note by physician #2 states in part, "The patient refuses medication due to their illness and there is a statutory Authority for treatment." The patient's medication orders state, "Cholecalciferol drops oral 125 mcg [micrograms] PO [by mouth] daily 0700 [7:00 a.m.] for low vitamin D, put in juice or flavored water with Cinacalcet. Cinacalcet tab [tablet] 60 mg PO daily 0700 for hypoparathyroidism, dissolving juice or flavored water. Cinacalcet tab 60 mg daily at 1700 [5:00 p.m.] for hypoparathyroidism, dissolve in orange juice at breakfast and dinner. Lithium carbonate 300 mg daily 1600 [4:00 p.m.], open capsule and finely crush granules, put in juice or flavored water for bipolar disorder. Lithium carbonate cap 300 mg PO daily at 1100 [11:00 a.m.], open capsule and finely crush granules, put in juice or flavored water for bipolar disorder. Olanzapine tab rapid disintegrate 15 mg PO daily at 1100 [11:00 a.m.] for bipolar/mood, put in juice or flavored water. Olanzapine tab rapid disintegrate 15 mg PO daily at 1600 [4:00 p.m.], mix in juice or flavored water for bipolar disorder. The patient's Master Treatment Plan dated 05/25/23 states in part, "[Patient #9] continues to receive medications in his beverages with meals to assist with compliance. Patient's Guardian has given consent." On 06/01/23, at 5:32 p.m. a progress note by the patient's physician states in part, "... Still with poor insight and judgment regarding presence of mental illness and need for medications. medications are concealed in liquids for compliance. [Patient #9] is only aware of taking invega.."

A review of facility policy, titled "Informed Consent/Right to Refuse Treatment", effective 07/01/21, states in pertinent part: "Procedures: ... III. Exceptions to Informed Consent/Right to Refuse Treatment A. In those instances when an involuntary committed patient rejects any proposed treatment and all attempts at negotiating an acceptable alternative have failed than the most conservative least intrusive treatment approach which is recognized as usual and customary for the diagnosed condition in which produces minimal potential side effects may be imposed over the objections of the patient if all of the following conditions are documented in the medical record: 1. The patient's refusal is a product of his or her illness; 2. The proposed treatment is recognized as appropriate, effective and within accepted standards of practice; 3. The proposed treatment is approved by the medical director; 4. The opinion of a second qualified practitioner concurs with the proposed treatment and; 5. The client Advocate is provided an opportunity to raise legitimate concerns on the part of the patient ..."

The West Virginia Health Care Surrogate Services Social Services Manual States in part: "G. Decision-Making for the Incapacitated Adult ... Note: Though the health care surrogate has decision making authority for health care matters, there are limits to what a health care surrogate can do. Specifically, appointment of a health care surrogate can not GUARANTEE that the adult will be compliant with a recommended course of treatment and/or medical care. While the health care surrogate does have a responsibility to authorize appropriate care/treatment, and to educate the adult to the extent possible about the benefits and consequences of compliance/failure to comply, they can not force the adult to exercise good judgment, take medications as prescribed, comply with medical procedures, etc. Also, as the incapacitated adult's authorized representative the Department does have access to the health information necessary to carry out our responsibilities as health care surrogate [HIPAA Privacy Rule 45 CFR. I64.502(g)]"

An interview was conducted with Licensed Practical Nurse (LPN) #1 on 06/06/23 at 9:39 a.m. Regarding patient #1, LPN #1 states in part, "We do have some patients that have orders to take their medications hidden in their food so they don't know that they're taking them."

An interview was conducted with the Chief Executive Officer (CEO) on 06/07/23 at 1:07 p.m. Regarding second opinion medications, and medication being concealed in food or beverage, the "Last Resort" procedure, the CEO explains the patient advocates are not notified, however they have full access to all the patient's medical records. The Medical Director does not sign off on all "Last Resort" medications. The patient's who don't have capacity, if all the proper policies and procedures are followed, they can be given medications with the permission of the Health Care Surrogate. If the patient could refuse all treatment, they could refuse to even be here.

Based on document review, and staff interview, it was determined the facility failed to follow their policy on the patient's right to refuse medications for all patients receiving care at the facility. This failure has the potential to cause great harm to all patients receiving care at the facility.

Findings include:

A review of facility policy, titled "Informed Consent/Right to Refuse Treatment", effective 07/01/21, states in pertinent part: "Procedures: ... III. Exceptions to Informed Consent/Right to Refuse Treatment A. In those instances when an involuntary committed patient rejects any proposed treatment and all attempts at negotiating an acceptable alternative have failed than the most conservative least intrusive treatment approach which is recognized as usual and customary for the diagnosed condition in which produces minimal potential side effects may be imposed over the objections of the patient if all of the following conditions are documented in the medical record: 1. The patient's refusal is a product of his or her illness; 2. The proposed treatment is recognized as appropriate, effective and within accepted standards of practice; 3. The proposed treatment is approved by the medical director; 4. The opinion of a second qualified practitioner concurs with the proposed treatment and; 5. The client Advocate is provided an opportunity to raise legitimate concerns on the part of the patient ..."

Review of W. Va. Code R. § 64-59-8 - Right to Refuse Treatment states in part: "8.1. General. As a participant in the program planning process, the patient has the right to exercise a voice in his or [patient #1] program plan and to object to or refuse aspects of the plan. 8.2. Use of Internal Discussion, Negotiation and Grievance Procedure. The patient's right to object to or refuse treatment is recognized as legitimate and shall be responded to in accordance with the provisions of the patient grievance procedure if informal discussion and negotiation do not resolve differences. 8.3. Alternatives Offered and Provided. The treatment team for any patient who has refused psychotropic medications or other recommended therapy shall meet and work to ensure that an agreed-upon effective alternative treatment is offered and provided if the patient consents. 8.4. Oral Refusal Overrides Prior Written Consent. An individual patient's oral refusal to accept medication or other treatment always overrides prior written consent except in emergency situations as defined in this rule or as required by the applicable standard of care. 8.5. Last Resort Procedure: When Patient Refuses Treatment. In those instances when an involuntarily committed patient rejects any proposed treatment and all attempts at negotiating an acceptable alternative have failed, then the most conservative, least intrusive treatment approach that is acceptable under the applicable standard of care for the diagnosed condition and which produces minimal potential side effects may be imposed over the objections of the patient if all the following conditions are documented in the patient's medical record: 8.5.1. The patient's refusal is a product of his or [patient #1] illness; 8.5.2. The proposed treatment is recognized as appropriate, effective and within accepted standards of practice; 8.5.3. The proposed treatment is approved by the clinical director; 8.5.4. The opinion of a second qualified practitioner concurs with the proposed treatment; and 8.5.5. The patient advocate is provided an opportunity to raise legitimate concerns on the part of the patient."

An interview was conducted with patient advocates #1 and #2 on 06/06/23 at 9:56 a.m. When asked about second opinion medications, and medications being given to a patient without their consent, the patient advocates states, "The facility notifies us when there's episodes of physical restraints and if the patient requires medication or injection in a psychiatric emergency. We also get notified of any Patient to Patient abuse. We are not notified of second opinion medications ordered. We are not on call so we are not here on weekends or nights to respond to any notifications ..."

An additional interview was conducted with the Medical Director (MD) on 06/06/23 at 2:00 p.m. Regarding the policy for patients' right to refuse medications, the MD explained the patient advocates are not notified ahead of time. The policy says client advocate, which is believed to be the HCS (Health Care Surrogate) or MPOA (Medical Power of Attorney).

An interview was conducted with the Chief Executive Officer (CEO) on 06/07/23 at 1:07 p.m. Regarding second opinion medications, and medication being concealed in food or beverage, the "Last Resort" procedure, the CEO explains, "the patient advocates are not notified, however they have full access to all the patient's medical records. The MD does not sign off on all "Last Resort" medications. The patient's who don't have capacity, if all the proper policies and procedures are followed, they can be given medications with the permission of the Health Care Surrogate. If the patient could refuse treatment, they could refuse to even be here."