HospitalInspections.org

Based on document review and staff interviews, it was determined the facility failed to ensure all staff are trained in correct procedures for reporting suspected or witnessed abuse/neglect. This failure has the potential to put all patients in the facility at risk of unreported abuse and/or neglect.

Findings include:

1. Facility Policy entitled "Patient Abuse/Neglect, or Exploitation", last reviewed 12/28/10, was reviewed on 1/20/15. It states, in part, "West Virginia Adult Protective Services Status Code 9.6.9 contains a mandatory reporting requirement that states that any and all mental health professionals must immediately report all actual or suspected cases of abuse or neglect to the Department of Human Services local Protective Service Agency. The employee observing abuse or receiving a report of abuse or neglect of a patient must report the incident to the Patient Advocate and to the Department of Human Services." It further states, "It is the responsibility of every employee to protect the patients' rights and assure freedom from abuse/neglect. Any employee witnessing abuse or having such abuse reported to him/her must report this information in compliance with Hospital Policy or be subject to disciplinary action."

2. The packet provided to staff entitled "How to Report Allegations of Abuse/Neglect" was reviewed with the Nurse Manager of Unit A-4 on 1/21/15. The third instruction was noted as "Complete Adult Protective Services (APS) Form", and the eighth instruction was noted as "Staff completing Grievance and APS Form must report to Adult Protective Services".

3. An interview was conducted with the Chief Nursing Executive (CNE) on 1/20/15 at 11:40 a.m. When asked how she trains her staff to respond to witnessed or suspected abuse/neglect, she responded, "They are taught to notify their supervisor or any person in authority, and then the supervisor will file an APS report".

4. An interview was conducted with LPN #1 on 1/20/15 at 3:00 p.m. When asked how he was taught to respond to witnessed or suspected abuse/neglect, he stated "I would report to the person above me". When asked if he would report directly to APS, he replied that he had done so in the past when he worked at a nursing home, but did not indicate he would do so in this facility.

5. An interview was conducted with LPN #2 on 1/21/15 at 7:33 a.m. When asked the procedure to follow in the event of witnessed or suspected abuse/neglect, she replied only, "I would go to my charge nurse".

6. An interview was conducted with Health Service Worker (HSW) #1 on 1/21/15 at 7:25 a.m. When asked the procedure to follow in the event of witnessed or suspected abuse/neglect, she replied only "I would report it immediately to my charge nurse."

7. An interview was conducted with HSW #2 on 1/21/15 at 7:45 a.m. When asked the procedure to follow in the event of witnessed or suspected abuse/neglect, she replied only, "I would report it to the Nurse Manager".

8. An interview was conducted with HSW #3 on 1/21/15 at 7:30 a.m. When asked the procedure to follow in the event of witnessed or suspected abuse/neglect, he replied only "I would tell the nurse or the Supervisor in charge".

9. An interview was conducted with HSW #4 on 1/20/15 at 1:20 p.m. When asked the procedure to follow in the event of witnessed or suspected abuse/neglect, she replied only, "I would tell the nurse".

Based on document review and staff interview, it was determined the facility failed to ensure a licensed staff member performed hourly spot checks on the unit's face check sheets per facility policy. Failure to ensure supervision of staff performing safety checks places all patients at risk of lapses in maintaining their safety and security.

Findings include:

1. Facility policy entitled "Unit Face Checks/Security Checks", last reviewed/revised 8/20/14, was reviewed on 1/21/15. It states, in part, "Licensed staff members (RN & LPN) should do spot checks hourly. They are to indicate the time that they did their spot checks at the bottom of the face check sheets".

2. An interview was conducted with the Chief Nursing Executive (CNE) on 1/20/15 at 11:40 a.m. She provided documentation of a November 2014 Staff Meeting Agenda, which stated, in part, "The RN's must do at LEAST hourly spot checks per policy". She stated it was her expectation that licensed personnel must do hourly spot checks on the face check sheets.

3. During the interview noted above, the Face Check Sheets for Unit A-4 dated 10/21/14 through 10/28/14 were reviewed. The CNE confirmed that licensed staff had not initialed the face check sheets hourly for at least one (1) eight-hour (8-hour) shift for all of the Face Check Sheets reviewed. She further agreed that review of the sheets revealed no licensed staff had initialed any spot checks completed for any of the three shifts for the dates 10/24/14, 10/26/14, or 10/27/14.