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The hospital failed to ensure the written process for prompt resolution of patient grievances was followed for one (1) of ten (10) patient records reviewed (patient #1). Cross refer to A 118.

The hospital failed to ensure all patients received care in a safe setting in regards to appropriate monitoring. This failure occurred for three (3) of ten (10) records reviewed (patients #8, 9 and 10). Cross refer to A 144.

The hospital failed to ensure the written process for investigation of an allegation of abuse or neglect occurred for one (1) of ten (10) patient records reviewed (patient #1). Cross refer to A 145.

The hospital failed to ensure a situation of potential neglect was reviewed for two (2) of ten (10) records reviewed (patients #9 and 10). Cross refer to A 145.

Based on record review, document review and staff interview it was determined the hospital failed to ensure the written process for prompt resolution of patient grievances was followed for one (1) of ten (10) patient records reviewed (patient #1). This failure has the potential for patients' rights to be violated when complaints and grievances are not investigated and resolved promptly in accordance with hospital policy.

Findings include:

1. Review of hospital policy, "Patient Grievance Policy", last reviewed 11/11/14, defines a grievance as: "A written or verbal complaint (when the verbal complaint about patient care is not resolved at the time of the complaint by staff present) that is made by a patient, or the patient's representative, regarding the patient's care, abuse or neglect...Patient grievances also include situations where patient or the patient's representative phone or write to Appalachian Regional Healthcare (ARH) about concerns related to care or services, or with an allegation of abuse or neglect...Complaints that are allegations of abuse or neglect must be reviewed immediately due to the seriousness of the allegation and the potential for harm to the patient. Established ARH policy concerning abuse and neglect must be initiated when a complaint of this nature is filed."

2. Review of the medical record for patient #1 revealed it was documented in the counselor progress notes and in the nursing notes that the patient's son made complaints about the patient's care during the admission between 12/18/14 and 1/2/15. The counselor documented on 12/31/14 the patient's son called and discussed his concerns about the staff being "mean" to the patient and "neglecting her". The counselor documented the patient's son was assured the patient was being well cared for. The nurse documented on 12/31/14: "Family talked to counselor about night shift staff..."

3. Review of a log of documented patient complaints/grievances for the time frame for this patient's complaint revealed there was no complaint documented.

4. The Director of Performance Improvement was interviewed on 4/6/15 at 11:45 a.m. She stated she was responsible for documenting and investigating patient complaints until the current Risk Manager began in her position the beginning of February 2015. She reviewed the documented complaints during the time frame the complaint was made regarding patient #1 and she stated there were no documented complaints. The current Risk Manager was interviewed on 4/7/15 at 10:50 a.m. and she also concurred there were no complaints documented for this patient and no investigation was made into the allegations of abuse or neglect.

5. The counselor was interviewed on 4/7/15 at 2:50 p.m. He stated he had discussed the son's concerns with him on the phone and he assured the son that the patient was not being abused or neglected. He stated he documented the son's complaint in the medical record but did not document it on a complaint or occurrence form and it was not sent through the appropriate channels as a complaint.

Based on record review, document review and staff interview it was determined the hospital failed to ensure all patients received care in a safe setting in regards to appropriate monitoring. This deficient practice was identified in three (3) of ten (10) records reviewed (patients #8, 9 and 10). This failure has the potential for harm for all patients when adequate monitoring does not occur.

Findings include:

1. On 4/8/15 at 10:35 a.m., the surveyor was conducting random observations on the Adult B unit of the Behavioral Science Unit and was accompanied by Clinical Manager #1. The Manager stated there were currently sixteen (16) patients on the sixteen (16)-bed unit. He stated it is expected each patient is directly observed and those observations are documented at least every fifteen (15) minutes on a check sheet.

The check sheets for all sixteen (16) patients were reviewed upon request. It was noted that for at least seven (7) of the current patients, the fifteen (15) minute checks were not being documented as required by hospital protocol. As an example, patient #8 had no fifteen (15) minute checks documented between 2:15 a.m. and 10:30 a.m. Patient #9 had no fifteen (15) minute checks documented between 7:30 a.m. and 10:30 a.m.

The Clinical Manager agreed with the above findings and stated that was in violation of hospital policy. Patient Care Assistant #1 was interviewed at the same time, and she stated she was responsible for the fifteen (15) minute checks on those patients, but she had been busy with giving baths to the patients needing total care and she had not been able to "keep up" with the fifteen (15) minute check sheets. She stated the other Personal Care Assistant was also busy transporting patients off the unit for x-rays or other reasons.

2. Review of the medical record for patient #9 revealed the 81 year old female patient was admitted on 3/24/15 with a diagnosis of schizoaffective disorder. The patient was noted to be ambulatory. The "Multidisciplinary Treatment Plan" was initiated on 3/24/15. As of the date of the review of the plan on 4/8/15, the plan was incomplete as there were no "Problems" listed nor were there planned "Interventions" listed. The "Treatment Plan Review" sheets had been filled out periodically. On 3/27/15 it was noted on the review: "Patient continues to be manic and going into other patient rooms." There was no specific plan indicated on how the patient would be kept safe and out of other patient rooms.

A nurse documented on 3/29/15 at 12:00 a.m.: "Upon entering patient room, found male patient (patient #10) in bed with (patient #9). Both were clothed and 'spooning'. Male patient removed and escorted to his room."

As noted on the finding above, the q fifteen (15) minute checks for patient #9 were not being done as hospital policy requires, even after the situation where a male patient had been found in bed with her and after it was documented she was noted to wander into other patient rooms.

3. Review of the medical record for patient #10 revealed the 74 year old male patient was admitted on 3/17/15 with "paranoid psychosis, dementia with disruptive behavior". The patient was placed on "assault precautions" at the time of admission. A nurse documented on 3/28/15 at 8:00 p.m.: "Pacing all over the unit and going into other patient rooms." On 3/29/15 at midnight the nurse noted: "Found patient in bed with female patient (#9) 'spooning'. Both did have their clothing. Patient removed from bed and assisted back to his own room." On 3/29/15 at 10:30 a.m. a nurse noted: "requires frequent re-direction due to going into other patient rooms." On 3/29/15 at 8:00 p.m. a nurse noted: "Patient needs re-direction not to go behind nursing station and into other's rooms." On 3/30/15 at 7:45 p.m. a nurse noted: "Patient has to be re-directed out of female patients' rooms, will continue to re-direct as needed."

Review of the "Multidisciplinary Treatment Plan" for the patient revealed there was no specific documented plan on how to manage the patient's wandering and intrusive behaviors in order to keep all patients on the unit safe.

4. Records #8 and 9 were reviewed with the Team Leader of Counselors, the Risk Manager and Clinical Manager #2 on 4/9/15 at 9:00 a.m. and they concurred with the findings.

A. Based on record review, document review and staff interview it was determined the hospital failed to ensure the written process for investigation of an allegation of abuse or neglect occurred for one (1) of ten (10) patient records reviewed (patient #1). This failure has the potential for patients' rights to be violated when allegations of abuse or neglect are not investigated and patients are not protected during any such investigation.

Findings include:

1. Review of policy, "Abuse/Neglect of Patients", last reviewed 7/23/15, reveals it outlines the appropriate steps for an investigation into any allegation of abuse or neglect of a patient. It states, in part: "As a condition of employment at Beckley Appalachian Regional Hospital any employee, volunteer, consultant, or student, who knows of or has reason to believe that an individual may have been abused, neglected, or exploited shall immediately report this information to Risk Management, Hospital CEO (Chief Executive Officer), or Administrative Person On-Call. The Risk Manager, CEO, or Administrative Person On-Call will then take steps to ensure the safety of the individual receiving services by doing any or all of the following..." The documented steps include notification, investigation, protecting the patient during the investigation and resolution of the allegation.

2. Review of the medical record for patient #1 revealed it was documented in the counselor progress notes and in the nursing notes that the patient's son made complaints about the patient's care during the admission between 12/18/14 and 1/2/15. The counselor documented on 12/31/14 the patient's son called and discussed his concerns about the staff being "mean" to the patient and "neglecting her". The counselor documented the patient's son was assured the patient was being well cared for. The nurse documented on 12/31/14: "Family talked to counselor about night shift staff..."

3. Review of a log of documented patient complaints/grievances for the time frame for this patient's complaint revealed there was no complaint documented.

4. The Director of Performance Improvement was interviewed on 4/6/15 at 11:45 a.m. She stated she was responsible for documenting and investigating patient complaints until the current Risk Manager began in her position the beginning of February 2015. She reviewed the documented complaints during the time frame the complaint was made to the counselor regarding patient #1 and she stated there were no documented complaints. The current Risk Manager was interviewed on 4/7/15 at 10:50 a.m. and she also concurred there were no complaints documented for this patient and no investigation was made into the allegations of abuse or neglect.

5. The counselor was interviewed on 4/7/15 at 2:50 p.m. He stated he had discussed the son's concerns with him on the phone and he assured the son the patient was not being abused or neglected. He stated he documented the son's complaint in the medical record but did not document it on a complaint or occurrence form and it was not sent through the appropriate channels as a complaint or as an allegation of abuse or neglect.

B. Based on record review and staff interview it was determined the hospital failed to ensure a situation of potential neglect was reviewed fortwo (2) of ten (10) records reviewed (patients #9 and 10). This failure has the potential for patients to be harmed when neglect occurs and a potential for the hospital to miss an opportunity to improve the quality and safety of care provided to all patients.

Findings include:

1. Review of the medical record for patient #9 revealed the 81 year old female patient was admitted on 3/24/15 with a diagnosis of schizoaffective disorder. The patient was noted to be ambulatory. The "Multidisciplinary Treatment Plan" was initiated on 3/24/15. As of the date of the review of the plan on 4/8/15, the plan was incomplete as there were no "Problems" listed nor were there planned "Interventions" listed. The "Treatment Plan Review" sheets had been filled out periodically. On 3/27/15 it was noted on the review: "Patient continues to be manic and going into other patient rooms." There was no specific plan indicated on how the patient would be kept safe and out of other patient rooms.

A nurse documented on 3/29/15 at 12:00 a.m.: "Upon entering patient room, found male patient (patient #10) in bed with (patient #9). Both were clothed and 'spooning'. Male patient removed and escorted to his room."

2. Review of the medical record for patient #10 revealed the 74 year old male patient was admitted on 3/17/15 with "paranoid psychosis, dementia with disruptive behavior". The patient was placed on "assault precautions" at the time of admission. A nurse documented on 3/28/15 at 8:00 p.m.: "Pacing all over the unit and going into other patient rooms." On 3/29/15 at midnight the nurse noted: "Found patient in bed with female patient (#9) 'spooning'. Both did have their clothing. Patient removed from bed and assisted back to his own room." On 3/29/15 at 10:30 a.m. a nurse noted: "requires frequent re-direction due to going into other patient rooms." On 3/29/15 at 8:00 p.m. a nurse noted: "Patient needs re-direction not to go behind nursing station and into other's rooms." On 3/30/15 at 7:45 p.m. a nurse noted: "Patient has to be re-directed out of female patients' rooms, will continue to re-direct as needed."

Review of the "Multidisciplinary Treatment Plan" for the patient revealed there was no specific documented plan on how to manage the patient's wandering and intrusive behaviors in order to keep all patients on the unit safe.

3. Records #8 and 9 were reviewed with the Team Leader of Counselors, the Risk Manager and Clinical Manager #2 on 4/9/15 at 9:00 a.m. and they concurred with the findings. The Risk Manager also stated the situation had not been reported to her or other members of the administrative team, and therefore it had not been reviewed as a potential neglect to determine if any change in processes may improve the safety of all patients.

Based on record review, document review and staff interview it was determined the hospital failed to ensure that clear expectations for safety are established in regards to appropriate monitoring. This deficient practice was identified in two (2) of ten (10) records reviewed (patients #9 and 10). This failure has the potential for harm for all patients when adequate monitoring does not occur and the potential for the hospital to miss opportunities to improve quality care and safety for all patients.

Findings include:

1. Review of the medical record for patient #9 revealed the 81 year old female patient was admitted on 3/24/15 with a diagnosis of schizoaffective disorder. The patient was noted to be ambulatory. The "Multidisciplinary Treatment Plan" was initiated on 3/24/15. As of the date of the review of the plan on 4/8/15, the plan was incomplete as there were no "Problems" listed nor were there planned "Interventions" listed. The "Treatment Plan Review" sheets had been filled out periodically. On 3/27/15 it was noted on the review: "Patient continues to be manic and going into other patient rooms." There was no specific plan indicated on how the patient would be kept safe and out of other patient rooms.

A nurse documented on 3/29/15 at 12:00 a.m.: "Upon entering patient room, found male patient (patient #10) in bed with (patient #9). Both were clothed and 'spooning'. Male patient removed and escorted to his room."

2. Review of the medical record for patient #10 revealed the 74 year old male patient was admitted on 3/17/15 with "paranoid psychosis, dementia with disruptive behavior". The patient was placed on "assault precautions" at the time of admission. A nurse documented on 3/28/15 at 8:00 p.m.: "Pacing all over the unit and going into other patient rooms." On 3/29/15 at midnight the nurse noted: "Found patient in bed with female patient (#9) 'spooning'. Both did have their clothing. Patient removed from bed and assisted back to his own room." On 3/29/15 at 10:30 a.m. a nurse noted: "requires frequent re-direction due to going into other patient rooms." On 3/29/15 at 8:00 p.m. a nurse noted: "Patient needs re-direction not to go behind nursing station and into other's rooms." On 3/30/15 at 7:45 p.m. a nurse noted: "Patient has to be re-directed out of female patients' rooms, will continue to re-direct as needed."

Review of the "Multidisciplinary Treatment Plan" for the patient revealed there was no specific documented plan on how to manage the patient's wandering and intrusive behaviors in order to keep all patients on the unit safe.

3. Records #8 and 9 were reviewed with the Team Leader of Counselors, the Risk Manager and Clinical Manager #2 on 4/9/15 at 9:00 a.m. and they concurred with the findings.

The Risk Manager also stated the situation of one (1) patient being found in bed with another patient had not been reported to her or other members of the administrative team, and therefore it had not been reviewed as a potential neglect to determine if any change in processes may improve the safety of all patients.

Based on record review, document review and staff interview it was determined the hospital failed to ensure the Registered Nurse adequately supervised the Patient Care Assistants in performing their assignment of doing a face to face check of every patient every fifteen (15) minutes as a required hospital procedure. This deficient practice was identified in two (2) of ten (10) records reviewed (patients #8 and 9). This failure has the potential for harm for all patients when adequate monitoring does not occur.

Findings include:

1. On 4/8/15 at 10:35 a.m., the surveyor was conducting random observations on the Adult B unit of the Behavioral Science Unit and was accompanied by Clinical Manager #1. The Manager stated there were currently sixteen (16) patients on the sixteen (16)-bed unit. He stated it is expected each patient is directly observed and those observations are documented at least every fifteen (15) minutes on a check sheet. The check sheets for all sixteen (16) patients were reviewed upon request. It was noted that for at least seven (7) of the current patients, the fifteen (15) minute checks were not being documented as required by hospital protocol. As an example, patient #8 had no fifteen (15) minute checks documented between 2:15 a.m. and 10:30 a.m. Patient #9 had no fifteen (15) minute checks documented between 7:30 a.m. and 10:30 a.m.

The Clinical Manager agreed with the above findings and stated that was in violation of hospital policy. Patient Care Assistant #1 was interviewed at the same time and she stated she was assigned to do the fifteen (15) minute checks on those patients, but she had been busy with giving baths to the patients needing total care and she had not been able to "keep up" with the qfifteen (15) minute check sheets. She stated the other Personal Care Assistant was also busy transporting patients off the unit for x-rays or other reasons.

2. The above findings were reviewed and discussed with Clinical Manager #2 on 4/9/15 at 9:00 a.m. and she agreed the Registered Nurse in charge of the unit on each shift is ultimately responsible for the monitorings assigned to the Patient Care Assistants.