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Based on review of medical records, document review and staff interviews it was revealed the facility failed to ensure the medical staff provided appropriate referral for emergency services, (see tag 093) failed to ensure verbal orders were not being used as a convenience to the provider and the Physician Assistant completed an assessment for a significant change in condition (see tag 063).

A. Based on review of medical records, document review and staff interviews it was revealed the facility failed to ensure verbal orders were not being used as a convenience to the provider. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A telephone interview was conducted with Physician Assistant (PA) #1 on 3/30/21 at 9:50 a.m. When asked about the incident with patient #1 she stated, "I was called Sunday evening, unsure of time, it was after supper, got called about the patient putting crayons in nose, ears and anus." She stated she did not come in to evaluate the patient. When asked why she did not come in Sunday evening to evaluate the patient she stated, "Because it was late Sunday evening." She stated she saw him on 3/15/21 at 9:35 a.m. She concurred she documented the patient had a sore throat/earache/discharge. She stated she notified the nurses the patient needed transported to the emergency department (ED) for foreign body removal. When asked if she wrote an order for transport to the ED she stated, "No, I told the nurses." When asked why she did not write the order she stated, "I had meetings, so I told Unit Manager he needed to be sent. I told her around 10:00 a.m." She stated she could see the foreign bodies, but the patient would not let her get near his ear. She stated, "Every time I tried to look in his ear he started screaming." She concurred she spoke to the Unit Manager in the p.m. on 3/15/21 due to the patient was not sent out to the ED.

2. A review of the Medical Staff Rules and Regulations, revised 3/16, stated in part: "ORDERS FOR TREATMENT- All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a Registered Nurse verbally via a telephone."

3. A telephone interview was conducted with the Medical Director on 3/30/21 at 12:00 p.m. When asked about verbal orders being given to the nurses when the medical staff is on the unit, he stated this is urgency, the PA should have entered the order for transfer to the ED herself and sent the patient to the ED. He stated the PA should have given a verbal order for transfer to the ED on Sunday if she did not want to come into the facility. He stated verbal orders cannot be given if you are in the building. When asked about Telehealth, he stated this isn't optimal, but they have to do the best they can do for these patients now. He stated because of COVID they had to do Telehealth. He stated they are in the process of hiring two (2) psychiatrists. He stated he is ashamed this occurred, and they will be addressing this immediately. He stated this borders on neglect.


B. Based on review of medical records, document review and staff interview it was revealed the facility failed to ensure the PA completed an assessment for a significant change in condition when notified on 3/14/21. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 2/27/21 with a diagnosis of behavioral disturbances and for rule out oppositional defiant disorder. On 3/14/21 at 10:52 p.m. Registered Nurse (RN) #1 stated in part: "Client has been oppositional. He was hitting staff. He was placed in a therapeutic hold. Intramuscular (IM) as necessary (PRN) meds were ordered and administered. He began hitting staff again. He was escorted to seclusion. In seclusion room he found small pieces of crayon peer before him had left. He put pieces in nose, ears, and anus. Pieces that could be removed were. He hit staff again and threw a stool at staff. He was secluded. IM PRN meds were ordered and administered. Doctor notified and orders obtained. Department of Health and Human Resources (DHHR) notified. Will maintain one to one (1:1) monitoring." There was no documentation in the medical record the patient was evaluated by the physician or Physician's Assistant (PA) after notification of patient #1 putting crayons in his nose, ears, and anus. On 3/15/21 at 3:07 a.m. it is documented patient #1 sleeping. On 3/15/21 at 2:56 p.m. a verbal order was obtained which stated, "transfer to emergency department (ED) for evaluation of foreign object." On 3/15/21 at 5:14 p.m. RN #2 stated in part: "Continues 1:1, patient combative with staff, running up and down halls, placed in small child restraint (SCR), also placed in second SCR for being combative with staff. Checked by PA in regard to crayons in both ears, unable to remove. Unit Manager notified, received order at approximately 3 p.m. for transport to emergency room (ER) for evaluation." Patient #1 was transported to the ED on 3/15/21 at approximately 6:06 p.m. On 3/15/21 at 9:28 p.m. RN #3 stated in part: "Special entry - pt. had put crayons in bilateral ears. Staff reported that cnp could not get them out. Psychiatrist #1 was notified, and orders received at approximately 3pm. Pt threw up after dinner. Pt started to in and out of consciousness, 911 was called by staff. Staff escorted pt. to the lobby were met fire truck/emt's. A male staff member went to ER with pt. Pt was transported to hospital. At the ER they were able to get the crayons out of pt.'s bilateral ears. CEO picked up pt. and BHT from hospital at approximately at 8:05 p.m. When got back to the hospital, staff escorted pt. to the unit. Pt has had no complaints the rest of this shift." On 3/15/21 at 9:29 p.m. a progress note from psychiatrist #1 stated in part: "Patient was unable to be seen this morning as he was heavily sedated after receiving IM injections for severe agitation and aggression including kicking and hitting staff, jumping on a male peer, and touching his genitals and inserting crayons into his ears and nose, as well as his rectum. He received Haldol/Ativan/Benadryl. He continues on 1:1 staffing for behaviors/aggression. He was under very poor behavioral control over the weekend. Update - received call from RN around 1730 (5:30 p.m.) reporting that patient was having altered level of consciousness and very sick. Order was given to Program Manager much earlier in day for patient to be taken to ED for proper evaluation after he had inserted crayons into various body cavities. I was not aware that patient had not been taken to the ED until RN called at 1730 (5:30 p.m.), by which time she had called 911 in order to get patient transported to the hospital immediately." Patient #1 was transported to the hospital at approximately 6:05 p.m. on 3/15/21. Patient #1 returned to the facility at approximately 8:30 p.m. There was no documentation in the medical record of any communication with the accepting facility concerning the patient's condition. Patient #1 was discharged to foster care on 3/22/21.

2. A review of the video for seclusion on 3/14/21 revealed patient #1 was in the seclusion room. At 8:27:30 p.m. patient #1 picks something up off the floor in the seclusion room and puts it in his left ear. At 8:41 p.m. seclusion episode was discontinued.

3. A telephone interview was conducted with PA #1 on 3/30/21 at 9:50 a.m. When asked about the incident with patient #1 she stated, "I was called Sunday evening, unsure of time, it was after supper. Got called about the patient putting crayons in nose, ears and anus." She stated she did not come in to evaluate the patient. When asked why she did not come in Sunday evening to evaluate the patient she stated, "Because it was late Sunday evening." She stated she saw him on 3/15/21 at 9:35 a.m. She concurred she documented the patient had a sore throat/earache/discharge. She stated she notified the nurses the patient needed transported to the ED for foreign body removal. When asked if she wrote an order for transport to the ED she stated, "No, I told the nurses." When asked why she did not write the order she stated, "I had meetings, so I told Unit Manager he needed to be sent. I told her around 10:00 a.m." She stated she could see the foreign bodies, but the patient would not let her get near his ear. She stated, "Every time I tried to look in his ear he started screaming." She concurred she spoke to the Unit Manager in the p.m. on 3/15/21 due to the patient was not sent out to the ED.

4. A review of the Medical Staff Rules and Regulations, revised 3/16, stated in part: "CALL-Providers who are on call are expected to return pages or phone calls within 30 minutes. The availability of the provider may also be anticipated at any time, therefore the ability of the provider to arrive at the facility within a reasonable time is also a requirement."

5. A telephone interview was conducted with the Medical Director on 3/30/21 at 12:00 p.m. When asked about the incident, he stated he received an email from the covering psychiatrist demanding corrective action. He stated he was informed the Chief Executive Officer (CEO) was looking into it and he had not heard anything else. When asked what the expectation would be for the on-call staff to come and assess a patient after hours, he stated the PA would be expected to do a visit and determine if they were unable to provide care, then send the patient for appropriate care. Medical services are around the clock. He stated the PA should have attempted to remove the crayons. When he was informed, she did not come in due to it was Sunday after dinner, he stated this is unacceptable. When asked about verbal orders being given to the nurses when the medical staff is on the unit, he stated this is urgency, the PA should have entered the order for transfer to the ED herself and sent the patient to the ED. He stated the PA should have given a verbal order for transfer to the ED on Sunday, if she did not want to come into the facility. He stated verbal orders cannot be given if you are in the building. When asked about Telehealth, he stated this isn't optimal, but they have to do the best they can do for these patients now. He stated because of COVID they had to do Telehealth. He stated they are in the process of hiring two (2) psychiatrists. He stated he is ashamed this occurred, and they will be addressing this immediately. He stated this borders on neglect.

Based on review of medical records and staff interviews it was revealed the facility failed to ensure medical staff were providing appropriate appraisal of emergencies, initial treatment, and referral for emergencies. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 2/27/21 with a diagnosis of behavioral disturbances and for rule out oppositional defiant disorder. On 3/14/21 at 10:52 p.m. Registered Nurse (RN) #1 stated in part: "Client has been oppositional. He was hitting staff. He was placed in a therapeutic hold. Intramuscular (IM) as necessary (PRN) meds were ordered and administered. He began hitting staff again. He was escorted to seclusion. In seclusion room he found small pieces of crayon peer before him had left. He put pieces in nose, ears, and anus. Pieces that could be removed were. He hit staff again and threw a stool at staff. He was secluded. IM PRN meds were ordered and administered. Doctor notified and orders obtained. Department of Health and Human Resources (DHHR) notified. Will maintain one to one (1:1) monitoring." There was no documentation in the medical record the patient was evaluated by the physician or Physician's Assistant (PA) after notification of patient #1 putting crayons in his nose, ears, and anus. On 3/15/21 at 3:07 a.m. it is documented patient #1 sleeping. On 3/15/21 at 2:56 p.m. a verbal order was obtained which stated, "transfer to emergency department (ED) for evaluation of foreign object." On 3/15/21 at 5:14 p.m. RN #2 stated in part: "Continues 1:1, patient combative with staff, running up and down halls, placed in small child restraint (SCR), also placed in second SCR for being combative with staff. Checked by PA in regard to crayons in both ears, unable to remove. Unit Manager notified, received order at approximately 3 p.m. for transport to emergency room (ER) for evaluation." Patient #1 was transported to the ED on 3/15/21 at approximately 6:06 p.m. On 3/15/21 at 9:28 p.m. RN #3 stated in part: "Special entry - pt. had put crayons in bilateral ears. Staff reported that cnp could not get them out. Psychiatrist #1 was notified, and orders received at approximately 3pm. Pt threw up after dinner. Pt started to in and out of consciousness, 911 was called by staff. Staff escorted pt. to the lobby were met fire truck/emt's. A male staff member went to ER with pt. Pt was transported to hospital. At the ER they were able to get the crayons out of pt.'s bilateral ears. CEO picked up pt. and BHT from hospital at approximately at 8:05 p.m. When got back to the hospital, staff escorted pt. to the unit. Pt has had no complaints the rest of this shift." On 3/15/21 at 9:29 p.m. a progress note from psychiatrist #1 stated in part: "Patient was unable to be seen this morning as he was heavily sedated after receiving IM injections for severe agitation and aggression including kicking and hitting staff, jumping on a male peer, and touching his genitals and inserting crayons into his ears and nose, as well as his rectum. He received Haldol/Ativan/Benadryl. He continues on 1:1 staffing for behaviors/aggression. He was under very poor behavioral control over the weekend. Update - received call from RN around 1730 (5:30 p.m.) reporting that patient was having altered level of consciousness and very sick. Order was given to Program Manager much earlier in day for patient to be taken to ED for proper evaluation after he had inserted crayons into various body cavities. I was not aware that patient had not been taken to the ED until RN called at 1730 (5:30 p.m.), by which time she had called 911 in order to get patient transported to the hospital immediately." Patient #1 was transported to the hospital at approximately 6:05 p.m. on 3/15/21. Patient #1 returned to the facility at approximately 8:30 p.m. There was no documentation in the medical record of any communication with the accepting facility concerning the patient's condition. Patient #1 was discharged to foster care on 3/22/21.

2. A review of the video for seclusion on 3/14/21 revealed patient #1 was in the seclusion room. At 8:27:30 p.m. patient #1 picks something up off the floor in the seclusion room and puts it in his left ear. At 8:41 p.m. seclusion episode was discontinued.

3. A telephone interview was conducted with PA #1 on 3/30/21 at 9:50 a.m. When asked about the incident with patient #1 she stated, "I was called Sunday evening, unsure of time, it was after supper. Got called about the patient putting crayons in nose, ears and anus." She stated she did not come in to evaluate the patient. When asked why she did not come in Sunday evening to evaluate the patient she stated, "Because it was late Sunday evening." She stated she saw him on 3/15/21 at 9:35 a.m. She concurred she documented the patient had a sore throat/earache/discharge. She stated she notified the nurses the patient needed transported to the ED for foreign body removal. When asked if she wrote an order for transport to the ED she stated, "No, I told the nurses." When asked why she did not write the order she stated, "I had meetings, so I told Unit Manager he needed to be sent. I told her around 10:00 a.m." She stated she could see the foreign bodies, but the patient would not let her get near his ear. She stated, "Every time I tried to look in his ear he started screaming." She concurred she spoke to the Unit Manager in the p.m. on 3/15/21 due to the patient was not sent out to the ED.

4. A review of the Medical Staff Rules and Regulations, revised 3/16, stated in part: "CALL-Providers who are on call are expected to return pages or phone calls within 30 minutes. The availability of the provider may also be anticipated at any time, therefore the ability of the provider to arrive at the facility within a reasonable time is also a requirement. ORDERS FOR TREATMENT-All orders for treatment shall be in writing. An order shall be considered to be in writing if dictated to a RN verbally via a telephone. "

5. A telephone interview was conducted with the Medical Director on 3/30/21 at 12:00 p.m. When asked about the incident, he stated he received an email from the covering psychiatrist demanding corrective action. He stated he was informed the Chief Executive Officer (CEO) was looking into it and he had not heard anything else. When asked what the expectation would be for the on-call staff to come and assess a patient after hours, he stated the PA would be expected to do a visit and determine if they were unable to provide care, then send the patient for appropriate care. Medical services are around the clock. He stated the PA should have attempted to remove the crayons. When he was informed, she did not come in due to it was Sunday after dinner, he stated this is unacceptable. When asked about verbal orders being given to the nurses when the medical staff is on the unit, he stated this is urgency, the PA should have entered the order for transfer to the ED herself and sent the patient to the ED. He stated the PA should have given a verbal order for transfer to the ED on Sunday, if she did not want to come into the facility. He stated verbal orders cannot be given if you are in the building. When asked about Telehealth, he stated this isn't optimal, but they have to do the best they can do for these patients now. He stated because of COVID they had to do Telehealth. He stated they are in the process of hiring two (2) psychiatrists. He stated he is ashamed this occurred, and they will be addressing this immediately. He stated this borders on neglect.

2021-3-024
A. Based on review of the medical record for patient #1 and staff interviews it was revealed the facility failed to provide care in a safe setting (see tag 144).


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2021-3-026
B. Based on video review, clinical record review, document review and staff interviews it was determined the facility failed to protect patient's rights, provide care in a safe setting, protect the patient from all types of abuse following hospital policy and ensure all staff follow their complaint policy. This failure was identified in one (1) out of thirty (30) patient record reviews (patient #2). These findings have the potential to place all patients at risk for abuse and injury. (See tags A 118, A 144 and A 145).

A. Noncompliance: The facility failed to ensure patient #2 was free from all forms of abuse or harassment, failed to ensure all staff follow facility policy to report abuse and complete and submit a Child Protective Services (CPS) Mandatory report within twenty-four (24) hours and immediately notify police and report staff involved in the abuse to the State in accordance with applicable West Virginia (WV) state law. This failure was identified in one (1) out of thirty (30) patient record reviews.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Failure to report abuse in accordance with WV State law to the police, CPS and the WV Board of Nursing places all patients at risk for future potential abuse. Although Registered Nurse #1 was not working, the facility did not report her to the WV Nursing Board following WV State law within 48 hours.

C. Need for Immediate action: The facility needs to correct their processes to implement reporting any CPS allegations of potential abuse and follow WV State Code and facility policy to report abuse within 24 hours to the State of WV, immediately notify the police and report nursing staff to the WV Board of Nursing.

D. An immediate plan of correction was received and sent to the State agency Program Director. It was accepted and the facility abated the Immediate Jeopardy (IJ) on 03/30/21 at 10:20 p.m.

Based on observation of video recordings, document review and interviews it was determined the facility failed to ensure all staff follow the facility grievance/complaint policy in the abuse of patient #2. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the Chief Executive Officer (CEO), a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ..."

5. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with Behavioral Health Technician (BHT) #2. When asked what the process is for reporting an incident, BHT #2 stated in part: "If someone got hurt or injured, you grab a form and give it to the RN. I don't know what happens after that. ..."

6. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the Interim Director of Nursing. When asked what the expectation is for staff to report abuse, she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and expect the Nurse Manager to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

7. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if they witnessed the incident, they verbalized they did not see what happened. When asked if the patient reported what happened, they stated in part: "I heard him tell other kids he was kicked by the nurse. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse, BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse they stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought she (the nurse) reported it."

2021-3-024
A. Based on review of the medical record for patient #1 and staff interviews it was revealed the facility failed to provide care in a safe setting. This failure was identified in one (1) of thirty (30) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 2/27/21 with a diagnosis of behavioral disturbances and for rule out oppositional defiant disorder. On 3/14/21 at 10:52 p.m. Registered Nurse (RN) #1 stated in part: "Client has been oppositional. He was hitting staff. He was placed in a therapeutic hold. Intramuscular (IM) as necessary (PRN) meds were ordered and administered. He began hitting staff again. He was escorted to seclusion. In seclusion room he found small pieces of crayon peer before him had left. He put pieces in nose, ears and anus. Pieces that could be removed were. He hit staff again and threw a stool at staff. He was secluded. IM PRN meds were ordered and administered. Doctor notified and orders obtained. Department of Health and Human Resources (DHHR) notified. Will maintain one to one (1:1) monitoring." There was no documentation in the medical record the patient was evaluated by the physician or Physician's Assistant (PA) after notification of patient #1 putting crayons in his nose, ears and anus. On 3/15/21 at 3:07 a.m. it is documented patient #1 sleeping. On 3/15/21 at 2:56 p.m. a verbal order was obtained which stated, "transfer to emergency department (ED) for evaluation of foreign object." On 3/15/21 at 5:14 p.m. RN #2 stated in part: "Continues 1:1, patient combative with staff, running up and down halls, placed in small child restraint (SCR), also placed in second SCR for being combative with staff. Checked by PA in regard to crayons in both ears, unable to remove. Unit Manager notified, received order at approximately 3 p.m. for transport to emergency room (ER) for evaluation." Patient #1 was transported to the ED on 3/15/21 at approximately 6:06 p.m. On 3/15/21 at 9:28 p.m. RN #3 stated in part: "Special entry - pt had put crayons in bilateral ears. Staff reported that cnp could not get them out. Psychiatrist #1 was notified and orders received at approximately 3pm. Pt threw up after dinner. Pt started to in and out of consciousness, 911 was called by staff. Staff escorted pt to the lobby where met fire truck/emt's. A male staff member went to ER with pt. Pt was transported to hospital. At the ER they were able to get the crayons out of pt's bilateral ears. CEO picked up pt and BHT from hospital at approximately at 8:05 p.m. When got back to the hospital, staff escorted pt to the unit. Pt has had no complaints the rest of this shift." On 3/15/21 at 9:29 p.m. a progress note from psychiatrist #1 stated in part: "Patient was unable to be seen this morning as he was heavily sedated after receiving IM injections for severe agitation and aggression including kicking and hitting staff, jumping on a male peer and touching his genitals and inserting crayons into his ears and nose, as well as his rectum. He received Haldol/Ativan/Benadryl. He continues on 1:1 staffing for behaviors/aggression. He was under very poor behavioral control over the weekend. Update - received call from RN around 1730 (5:30 p.m.) reporting that patient was having altered level of consciousness and very sick. Order was given to Program Manager much earlier in day for patient to be taken to ED for proper evaluation after he had inserted crayons into various body cavities. I was not aware that patient had not been taken to the ED until RN called at 1730 (5:30 p.m.), by which time she had called 911 in order to get patient transported to the hospital immediately." Patient #1 was transported to the hospital at approximately 6:05 p.m. on 3/15/21. Patient #1 returned to the facility at approximately 8:30 p.m. There was no documentation in the medical record of any communication with the accepting facility concerning the patient's condition. Patient #1 was discharged to foster care on 3/22/21.

2. A review of the video for seclusion on 3/14/21 revealed patient #1 was in the seclusion room. At 8:27:30 p.m. patient #1 picks something up off the floor in the seclusion room and puts it in his left ear. At 8:41 p.m. seclusion episode was discontinued.

3. A telephone interview was conducted with PA #1 on 3/30/21 at 9:50 a.m. When asked about the incident with patient #1 she stated, "I was called Sunday evening, unsure of time, it was after supper. Got called about the patient putting crayons in nose, ears and anus." She stated she did not come in to evaluate the patient. When asked why she did not come in Sunday evening to evaluate the patient she stated, "Because it was late Sunday evening." She stated she saw him on 3/15/21 at 9:35 a.m. She concurred she documented the patient had a sore throat/earache/discharge. She stated she notified the nurses the patient needed transported to the ED for foreign body removal. When asked if she wrote an order for transport to the ED she stated, "No, I told the nurses." When asked why she did not write the order she stated, "I had meetings so I told Unit Manager he needed to be sent. I told her around 10:00 a.m." She stated she could see the foreign bodies, but the patient would not let her get near his ear. She stated, "Every time I tried to look in his ear he started screaming." She concurred she spoke to the Unit Manager in the p.m. on 3/15/21 due to the patient was not sent out to the ED.

4. A telephone interview was conducted with the Nurse Manager (NM) on 3/30/21 at 11:10 a.m. When asked about the patient she stated, "I remembered when I came in on the Monday I was informed the patient had put something up his nose, possibly his ears and butt also." She stated the PA said she could not get it out. She stated she and the PA did discuss possibly sending him out to the ED on 3/15/21 around 10:00 a.m. or 11:00 a.m. She stated the patient was very "wiggly" when the PA was trying to get the crayons out of his ears. She stated when she and the PA were discussing possible transfer to the ED, she did not take it as an order. She stated later she spoke to the PA to verify what she wanted to do with the patient and the PA verified to transfer him out to the ED. She stated this was around 3:00 p.m. when the PA verified the order for transfer. A verbal order was taken.

5. A telephone interview was conducted with Psychiatrist #1 on 3/30/21 at 11:10 a.m. He stated he remembered the case well. He stated another physician admitted the patient. He stated he wasn't on call when the incident occurred. When asked if he expected the PA to physically see the patient when called, he stated not necessarily. He stated if nursing felt the patient should go to the hospital then they should have sent him to the hospital. He stated they do that all the time. When asked if the physicians make notes when notified about patient concerns, he stated no, the nurses make the notes they contacted the physicians. He stated they make notes when they examine the patient. He stated the patient was one to one (1:1) and doesn't know how the patient got parts of crayons anyway. He stated the patient was supposed to go to the ED and did not go for a significant time later. He stated he spoke with the PA earlier on 3/15/21 and the PA gave an order around 10:00 a.m. to transport the patient to the ED. When asked if the PA should have written the order, he said the PA can put in the order or give a verbal order to the nurses to put in the order. He stated this was a level of urgency and the patient should have been taken out that morning. He stated it was a major lack of communication.

6. A telephone interview was conducted with the Medical Director on 3/30/21 at 12:00 p.m. When asked about the incident, he stated he received an email from the covering psychiatrist demanding corrective action. He stated he was informed the Chief Executive Officer (CEO) was looking into it and he had not heard anything else. When asked what the expectation would be for the on call staff to come and assess a patient after hours, he stated the PA would be expected to do a visit and determine if they were unable to provide care, then send the patient for appropriate care. Medical services are around the clock. He stated the PA should have attempted to remove the crayons. When he was informed she did not come in due to it was Sunday after dinner, he stated this is unacceptable. When asked about verbal orders being given to the nurses when the medical staff is on the unit, he stated this is urgency, the PA should have entered the order for transfer to the ED herself and sent the patient to the ED. He stated the PA should have given a verbal order for transfer to the ED on Sunday, if she did not want to come into the facility. He stated verbal orders cannot be given if you are in the building. When asked about Telehealth, he stated this isn't optimal, but they have to do the best they can do for these patients now. He stated because of COVID they had to do Telehealth. He stated they are in the process of hiring two (2) psychiatrists. He stated he is ashamed this occurred and they will be addressing this immediately. He stated this borders on neglect.




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B. Based on observation of video recordings, clinical record review, document review and staff interviews it was determined the facility failed to provide patient care in a safe setting for patient #2 by failing to report abuse following policy and procedures and in accordance with West Virginia State Law. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the CEO, a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ..."

5. A review of WV State Code §49-2-803 states in part: "Persons mandated to report suspected abuse and neglect; requirements. (a) Any medical, dental, or mental health professional, Christian Science practitioner, religious healer, school teacher or other school personnel, social service worker, child care or foster care worker, emergency medical services personnel, peace officer or law-enforcement official, humane officer, member of the clergy, circuit court judge, family court judge, employee of the Division of Juvenile Services, magistrate, youth camp administrator or counselor, employee, coach or volunteer of an entity that provides organized activities for children, or commercial film or photographic print processor who has reasonable cause to suspect that a child is neglected or abused, including sexual abuse or sexual assault, or observes the child being subjected to conditions that are likely to result in abuse or neglect shall immediately, and not more than twenty-four (24) hours after suspecting this abuse or neglect, report the circumstances to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse or sexual abuse or sexual assault, the reporter shall also immediately report to the State Police and any law-enforcement agency having jurisdiction to investigate the complaint."

6. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was not any documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by PA #1, revealed the assessment does not document the patient was being examine for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

7. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse, she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO. ... and we reviewed the video together. ... On 03/24/21 I called RN #1, with NM #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to FaceTimed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had someone call back and the police came on 03/26/21." When asked if the Interim Director of Nursing (IDON) was notified, she stated in part: "We are reporting to the Nursing Board. This is done by NM #1 or the IDON. They have been appraised of everything on 03/24/21." When asked when they will be reporting the nurse to the RN Board of WV, she stated in part: "The IDON will be filing it tomorrow to the WV Board of Nursing."

8. An interview was conducted on 03/30/21 at approximately 11:21 a.m. with PA #1. When asked if she was notified if patient #2 was abused on 03/20/21 by a staff member, she stated in part: "I was requested by administration to examine him on 03/25/21. ... I asked him (patient) if he had gotten hit or kicked and he denied it. I examined him and he had no issues. I was notified when the Director of Risk and Quality came to me. I did not see the video and no one said anything. I did look at his head and in his hair and didn't see anything. I don't know if the psychiatrist was notified."

9. An interview was conducted on 03/30/21 at approximately 11:50 a.m. with the Program Electronic Health Record Manager. When asked if there were any reports in patient #2's clinical record for nursing notes and physician notes documenting and notifying the physician of a staff member hitting or kicking patient #2 or any assessments assessing the patient for getting kicked or hit by a staff member, he concurred there were not any notes or reports.

10. An interview was conducted on 03/30/21 at approximately 12:48 p.m. with the Director of Risk and Quality. When asked when they reported the abuse to the State he stated in part: "The CEO sent it ... I sent it to him on the 03/25/21." When asked when the incident was discovered he stated in part: "The Director of HR discovered it on 03/23/21." When asked when the police were notified he stated in part: "I notified them on 03/24/21. I called the State Police. They didn't know if they had jurisdiction. I did get a call from the office ... from Charleston. ... They came on 03/26/21." When asked who is responsible for documenting the abuse in the patient's chart he stated in part: "It should be the NM on the unit when you have something like that. ... We are taking our employee's confidentiality into consideration. I would expect someone in Nurse Management would do that. But again, how this was discovered, it's a little difficult because it was found by Administration." When asked about a lack of documentation of the patient's abuse by a physician he stated in part: "I think the PA #1 should have had more detail in the assessment."

11. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with BHT #2. When asked what the process is for reporting an incident BHT #2 stated in part: "If someone got hurt or injured you grab a form and give it to the RN. I don't know what happens after that. ..."

12. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the IDON. When asked what the expectation is for staff to report abuse she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and I expect the NM to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

13. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if BHT #3 witnessed the incident, BHT #3 verbalized they did not see what happened. When asked if the patient reported what happened BHT #3 stated in part: "I heard him tell other kids he was kicked. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse BHT #3 stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought the nurse reported it."

14. An interview was conducted on 04/01/21 at approximately 8:13 a.m. with the Medical Director. When notified of patient #2's abuse by staff on 03/20/21 and asked what his expectation is for notifying the physician, he stated in part: "I expect the attending to be notified immediately of what happened to take care of the patient and they should follow up the next day and interview the person of the incident. It's not just about the nurse and they should have assessed the other person (patient). I can see there are issues. I would expect it to be in the notes of the chart." When asked how soon he expects it to be reported he stated in part: "That needs to be reported immediately. If it was not reported then staff could not do the exam." When notified the patient had an exam on 03/25/21 and the assessment did not document any information the patient was abused or was kicked by staff, he stated in part: "They should have documented the results of the exam and the patient was assessed for signs of any injury related to the abuse. I would expect better documentation of assessing the patient and a description of the incident. The attending needs to be notified immediately and the patient assessed for the consequences of the action. ... Things happen and I don't get made aware of it right away. There is fragmentation of information. If the provider doesn't document the information, then the attending doesn't know what happened and nursing doesn't know what happened for continuous care of the patient."

C. Based on observation of video recordings, clinical record review, document review and staff interviews it was determined the facility failed to provide patient care in a safe setting for patient #2 and notify the physician immediately of abuse and a change in patient condition. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the CEO, a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. RN #1 and BHT #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom blocking the view of the interaction between the RN and patient. At the same time the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient, the RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV."

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ..."

5. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

6. A review of facility policy, "Nursing Assessment/Reassessment," revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. A review of "Highland Hospital Medical Staff Rules and Regulations," approved 03/29/26, stated in part: "Progress notes shall be entered into the medical record daily by a Physician, or his / her designee. At a minimum, the progress note shall describe treatment interventions, the rationale for the intervention, and the patient's response to these interventions. Progress notes should be recorded at the time of observation and contain enough substance and detail to facilitate continuity of care. Notes made by a designee shall be initialed by the attending physician. The physician shall enter into the medical record a progress note, at a minimum, weekly for Partial Hospitalization and Subacute patients."

8. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO. ... and we reviewed the video together. ... On 03/24/21 I called RN #1, with Nurse Manager (NM) #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to FaceTimed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had someone call back and the police came on 03/26/21." When asked if the Interim Director of Nursing was notified she stated in part: "We are reporting to the nursing board. This is done by NM #1 or the Interim Director of Nursing. They have been appraised of everything on 03/24/21." When asked when they will be reporting the nurse to the RN Board of WV she stated in part: "The Interim Director of Nursing will be filing it tomorrow to the W

Based on observation of video recordings, clinical record review, document review and staff interview the facility failed to ensure patient #2 was free from all forms of abuse or harassment. The facility failed to follow policies and procedures and complete and submit a Child Protective Services (CPS) Mandatory report in accordance with applicable West Virginia State law. This failure was identified in one (1) out of thirty (30) patient record reviews.

Findings include:

1. In the presence of the Chief Executive Officer (CEO), a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

5. A review of WV State Code §49-2-803 states in part: "Persons mandated to report suspected abuse and neglect; requirements. (a) Any medical, dental, or mental health professional, Christian Science practitioner, religious healer, school teacher or other school personnel, social service worker, child care or foster care worker, emergency medical services personnel, peace officer or law-enforcement official, humane officer, member of the clergy, circuit court judge, family court judge, employee of the Division of Juvenile Services, magistrate, youth camp administrator or counselor, employee, coach or volunteer of an entity that provides organized activities for children, or commercial film or photographic print processor who has reasonable cause to suspect that a child is neglected or abused, including sexual abuse or sexual assault, or observes the child being subjected to conditions that are likely to result in abuse or neglect shall immediately, and not more than twenty-four (24) hours after suspecting this abuse or neglect, report the circumstances to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse or sexual abuse or sexual assault, the reporter shall also immediately report to the State Police and any law-enforcement agency having jurisdiction to investigate the complaint."

6. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

7. A review of facility policy, "Nursing Assessment/Reassessment," revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

8. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse, she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO ... and we reviewed the video together. ... On 03/24/2, I called RN #1, with Nurse Manager (NM) #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to Face Timed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had someone call back and the police came on 03/26/21." When asked if the Interim Director of Nursing was notified, she stated in part: "We are reporting to the nursing board. This is done by NM #1 or the Interim Director of Nursing. They have been appraised of everything on 03/24/21." When asked when they will be reporting the nurse to the RN Board of WV, she stated in part: "The Interim Director of Nursing will be filing it tomorrow to the WV Board of Nursing."

9. An interview was conducted on 03/30/21 at approximately 11:21 a.m. with PA #1. When asked if she was notified if patient #2 was abused on 03/20/21 by a staff member, she stated in part: "I was requested by administration to examine him on 03/25/21. ... I asked him (patient) if he had gotten hit or kicked, and he denied it. I examined him and he had no issues. I was notified when the Director of Risk and Quality came to me. I did not see the video, and no one said anything. I did look at his head and, in his hair, and didn't see anything. I don't know if the psychiatrist was notified."

10. An interview was conducted on 03/30/21 at approximately 11:50 a.m. with the Program Electronic Health Record Manager. When asked if there were any reports in patient #2's clinical record for nursing notes and physician notes documenting and notifying the physician of a staff member hitting or kicking patient #2 or any assessments assessing the patient for getting kicked or hit by a staff member, he concurred there were not any notes or reports.

11. An interview was conducted on 03/30/21 at approximately 12:48 p.m. with the Director of Risk and Quality. When asked when they reported the abuse to the State he stated in part: "CEO sent it ... I sent it to him on the 03/25/21." When asked when the incident was discovered he stated in part: "The Director of HR discovered it on 03/23/21." When asked when the police were notified, he stated in part: "I notified them on 03/24/21. I called the State Police. They didn't know if they had jurisdiction. I did get a call from the office ... from Charleston. ... They came on 03/26/21." When asked who is responsible for documenting the abuse in the patient's chart, he stated in part: "It should be the Nurse Manager on the unit when you have something like that. ... We are taking our employee's confidentiality into consideration. I would expect someone in Nurse Management would do that, but again, how this was discovered, it's a little difficult because it was found by Administration." When asked about a lack of documentation of the patient's abuse by a physician he stated in part: "I think the PA #1 should have had more detail in the assessment."

12. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with BHT #2. When asked what the process is for reporting an incident, BHT #2 stated in part: "If someone got hurt or injured you grab a form and give it to the RN. I don't know what happens after that. ..."

13. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the Interim Director of Nursing. When asked what the expectation is for staff to report abuse, she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and I expect the NM to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

14. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if BHT #3 witnessed the incident, BHT #3 verbalized they did not see what happened. When asked if the patient reported what happened BHT #3 stated in part: "I heard him tell other kids he was kicked. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse BHT #3 stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought the nurse reported it."

15. An interview was conducted on 04/01/21 at approximately 8:13 a.m. with the Medical Director. When notified of patient #2's abuse by staff on 03/20/21 and asked what his expectation is for notifying the physician, he stated in part: "I expect the attending to be notified immediately of what happened to take care of the patient and they should follow up the next day and interview the person of the incident. It's not just about the nurse and they should have assessed the other person (patient). I can see there are issues. I would expect it to be in the notes of the chart." When asked how soon he expects it to be reported he stated in part: "That needs to be reported immediately. If it was not reported then staff could not do the exam." When notified the patient had an exam on 03/25/21 and the assessment did not document any information the patient was abused or was kicked by staff, he stated in part: "They should have documented the results of the exam and the patient was assessed for signs of any injury related to the abuse. I would expect better documentation of assessing the patient and a description of the incident. The attending needs to be notified immediately and the patient assessed for the consequences of the action. ... Things happen and I don't get made aware of it right away. There is fragmentation of information. If the provider doesn't document the information, then the attending doesn't know what happened and nursing doesn't know what happened for continuous care of the patient."

B. Based on video review, clinical record review, document review and interview Physician Assistant (PA) #1 failed to follow medical staff bylaws, rules and regulations and medical records documentation policies by failing to document a complete and accurate physical assessment of patient #2 when evaluating the patient for potential physical and mental abuse injuries. This failure was identified in one (1) out of thirty (30) patient clinical records. This failure has the potential to place for all patients at risk for inadequate medical care and injury related to inaccurate and incomplete clinical records.

A. Noncompliance: PA #1 failed to document a complete and accurate assessment for physical and emotional abuse in patient #2's clinical record. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential to place all patients at risk for inadequate medical care and injury.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Failing to document physical abuse and outcomes in the clinical record can cause an adverse event due to inaccurate, unknown and inconsistent care to the patient and not address any mental or emotional events caused by the physical abuse.

C. Need for Immediate Action: The facility needs to correct their processes to ensure medical staff document complete and accurate physical assessments of abuse and incidents occurring to patients for continuity of care.

D. An immediate plan of correction was received and sent to the State agency Program Director. It was accepted and the facility abated the IJ on 03/30/21 at 10:20 p.m.

Findings include:

1. In the presence of the Chief Executive Officer (CEO), a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

3. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

4. A review of "Highland Hospital Medical Staff Rules and Regulations," approved 03/29/26, stated in part: "Progress notes shall be entered into the medical record daily by a Physician, or his / her designee. At a minimum, the progress note shall describe treatment interventions, the rationale for the intervention, and the patient's response to these interventions. Progress notes should be recorded at the time of observation and contain enough substance and detail to facilitate continuity of care. Notes made by a designee shall be initialed by the attending physician. The physician shall enter into the medical record a progress note, at a minimum, weekly for Partial Hospitalization and Subacute patients."

5. A review of facility policy, "Documentation in Medical Records," revised 10/01/05, states in part: "It is Highland Hospital's policy that an accurate and complete medical record shall be maintained on each patient who is admitted to a hospital program. Each medical record shall contain information sufficient to identify the patient, justify the admission and treatment or services provided, document all significant clinical information, and document information as necessary for continuity of care and any instructions given to the patient (or significant other) upon discharge from the program. ... Each clinical event shall be documented as soon as possible after its occurrence. ...Completeness implies that the required forms are assembled and authenticated, all final diagnoses are recorded without use of abbreviations, and transcription of any dictated information is completed and inserted in the medical record. Timeliness requirements for ancillary reports (e.g., psychologic reports, initial social assessments, activities assessments, dietary assessments) have been established and shall be adhered to by employees responsible for generating the reports."

6. An interview was conducted on 03/30/21 at approximately 11:21 a.m. with PA #1. When asked if she was notified if patient #2 was abused on 03/20/21 by a staff member, she stated in part: "I was requested by administration to examine him on 03/25/21. ... I asked him (patient) if he had gotten hit or kicked and he denied it. I examined him and he had no issues. I was notified when the Director of Risk and Quality came to me. I did not see the video and no one said anything. I did look at his head and in his hair and didn't see anything. I don't know if the psychiatrist was notified."

7. An interview was conducted on 03/30/21 at approximately 11:50 a.m. with the Program Electronic Health Record Manager. When asked if there were any reports in patient #2's clinical record for nursing notes and physician notes documenting and notifying the physician of a staff member hitting or kicking patient #2 or any assessments assessing the patient for getting kicked or hit by a staff member, he concurred there were not any notes or reports.

8. An interview was conducted on 03/30/21 at approximately 12:48 p.m. with the Director of Risk and Quality. When asked when they reported the abuse to the State he stated in part: "CEO sent it ... I sent it to him on the 03/25/21." When asked when the incident was discovered he stated in part: "The Director of HR discovered it on 03/23/21." When asked when the police were notified he stated in part: "I notified them on 03/24/21. I called the State Police. They didn't know if they had jurisdiction. I did get a call from the office ... from Charleston. ... They came on 03/26/21." When asked who is responsible for documenting the abuse in the patient's chart, he stated in part: "It should be the Nurse Manager on the unit when you have something like that. ... We are taking our employee's confidentiality into consideration. I would expect someone in Nurse Management would do that, but again, how this was discovered, it's a little difficult because it was found by Administration." When asked about a lack of documentation of the patient's abuse by a physician he stated in part: "I think the PA #1 should have had more detail in the assessment."

9. An interview was conducted on 04/01/21 at approximately 8:13 a.m. with the Medical Director. When notified of patient #2's abuse by staff on 03/20/21 and asked what his expectation is for notifying the physician, he stated in part: "I expect the attending to be notified immediately of what happened to take care of the patient and they should follow up the next day and interview the person of the incident. It's not just about the nurse and they should have assessed the other person (patient). I can see there are issues. I would expect it to be in the notes of the chart." When asked how soon he expects it to be reported he stated in part: "That needs to be reported immediately. If it was not reported then staff could not do the exam." When notified the patient had an exam on 03/25/21 and the assessment did not document any information the patient was abused or was kicked by staff, he stated in part: "They should have documented the results of the exam and the patient was assessed for signs of any injury related to the abuse. I would expect better documentation of assessing the patient and a description of the incident. The attending needs to be notified immediately and the patient assessed for the consequences of the action. ... Things happen and I don't get made aware of it right away. There is fragmentation of information. If the provider doesn't document the information, then the attending doesn't know what happened and nursing doesn't know what happened for continuous care of the patient."

2021-3-024
A. Based on a review of medical records and staff interviews it was revealed nursing staff failed to provide services as ordered by the physician (see tag A 392) and failed to administer medications as per physician's orders/per hospital policy (see tag A 398).


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2021-3-026
B. Based on video observation, clinical record review, document review and staff interviews it was revealed the facility failed to ensure nursing staff supervise and evaluate nursing care for patient #2 following changes in patient condition to the provider and failed to follow facility policies and procedures for reporting abuse, grievances and incidents. This failure was identified in one (1) out of thirty (30) patient record reviews. These findings have the potential for all patients to be at risk for abuse and injury. (See tags A 395 and A 398).

A. Noncompliance: The Interim Director of Nursing failed to ensure all nursing staff supervise and evaluate patient care and notify the provider immediately of patient #2's abuse when known and follow facility policies for reporting a patient grievance, an incident report and a Child Protective Services Mandatory report in accordance with applicable West Virginia State law. This failure was identified in one (1) out of Thirty (30) patient record reviews. This failure had the potential to place all patients at risk for abuse and injury.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Facility staff not notifying the provider immediately or as soon as possible can place the patient at risk for a physical or mental adverse event.

C. Need for Immediate Action: The facility needs to correct their processes to ensure providers are immediately notified as soon as possible of any injuries or events that can cause changes in patient condition.

D. An immediate plan of correction was received and sent to the State agency Program Director. It was accepted and the facility abated the IJ on 03/30/21 at 10:20 p.m.

Based on review of medical records, review of documents and staff interviews it was revealed nursing staff failed to provide services as ordered by the physician. This failure was identified in two (2) of thirty (30) medical records reviewed (patient #1 and 4). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 2/27/21 with a diagnosis of behavioral disturbances and for rule out oppositional defiant disorder. On 3/14/21 at 10:52 p.m. Registered Nurse (RN) #1 stated in part: "Client has been oppositional. He was hitting staff. He was placed in a therapeutic hold. IM PRN meds were ordered and administered. He began hitting staff again. He was escorted to seclusion. In seclusion room he found small pieces of crayon peer before him had left. He put pieces in nose, ears and anus. Pieces that could be removed were. He hit staff again and threw a stool at staff. He was secluded. Intramuscular (IM) as necessary (PRN) meds were ordered and administered. Doctor notified and orders obtained. A review of the administration of medication revealed Ativan two (2) milligrams per one (1) milliliter was administered at 4:30 p.m. on 3/14/21 and at 10:30 p.m. on 3/14/21. A review of the medication orders revealed an order that stated, "Order # 312586, Date: 3/14/21 time: 10:33 p.m., Ativan 2mg/1cc injection solution, 1 mg one time only, start time 3/14/21 4:30 p.m. end time: 3/15/21 4:29 p.m. and a second order for 3/14/21 "Order # 312588, Date: 3/14/21 time: 10:33 p.m., Ativan 2mg/1cc injection solution, 1 mg one time only, start time 3/14/21 4:30 p.m. end time: 3/15/21 4:29 p.m." No correct order for the injections of Ativan on 3/14/21 was noted in the medical record. Order #1 and order #2 are identical except for the order number.

2. A review of the policy titled, "Medication Administration, revised 11/19, stated in part: "Medications will be administered as per physician's order."

3. An interview was conducted with the Interim Director of Nursing (IDON) on 3/30/21 at 5:50 p.m. She concurred no appropriate order was obtained for the intramuscular injections given to patient #1 on 3/14/21. When asked when the order is to be entered for all medications, she stated immediately or as soon as possible.

4. A review of the medical record for patient #4 revealed patient #4 was admitted for depression and aggression. On 3/13/21 it is documented patient #4 was placed in restraints on 5:56 p.m. Patient #4 was placed in seclusion on 3/14/21 at 6:12 p.m. At 6:23 p.m. seclusion was discontinued. A review of the orders revealed no order for seclusion.

5. A review of the policy titled, "SECLUSION AND RESTRAINT, revised 12/20, stated in part: "Seclusion and Restraint requires a time-limited physician's order."

6. A telephone interview was conducted with the IDON on 4/1/21 at 9:33 a.m. She concurred there was no order for seclusion for 3/13/21. She stated the policy does not state and order for restraints can be taken to the less restrictive on the same order. She did not concur a separate order for seclusion was needed.

Based on clinical record review, document review and interview the Interim Director of Nursing failed to supervise and evaluate the nursing care for patient #2 by ensuring the provider was notified immediately by the nursing department as soon as it was known the patient was abused. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the Chief Executive Officer (CEO), a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. Registered Nurse (RN) #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

5. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

6. A review of facility policy, "Nursing Assessment/Reassessment," revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. A review of "Highland Hospital Medical Staff Rules and Regulations," approved 03/29/26, stated in part: "Progress notes shall be entered into the medical record daily by a Physician, or his / her designee. At a minimum, the progress note shall describe treatment interventions, the rationale for the intervention, and the patient's response to these interventions. Progress notes should be recorded at the time of observation and contain enough substance and detail to facilitate continuity of care. Notes made by a designee shall be initialed by the attending physician. The physician shall enter into the medical record a progress note, at a minimum, weekly for Partial Hospitalization and Subacute patients."

8. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse, she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO ... and we reviewed the video together. ... On 03/24/2, I called RN #1, with Nurse Manager (NM) #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to Face Timed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had someone call back and the police came on 03/26/21." When asked if the Interim Director of Nursing was notified, she stated in part: "We are reporting to the nursing board. This is done by NM #1 or the Interim Director of Nursing. They have been appraised of everything on 03/24/21." When asked when they will be reporting the nurse to the RN Board of WV, she stated in part: "The Interim Director of Nursing will be filing it tomorrow to the WV Board of Nursing."

9. An interview was conducted on 03/30/21 at approximately 11:21 a.m. with Physician Assistant (PA) #1. When asked if she was notified if patient #2 was abused on 03/20/21 by a staff member, she stated in part: "I was requested by administration to examine him on 03/25/21. ... I asked him (patient) if he had gotten hit or kicked, and he denied it. I examined him and he had no issues. I was notified when the Director of Risk and Quality came to me. I did not see the video, and no one said anything. I did look at his head and, in his hair, and didn't see anything. I don't know if the psychiatrist was notified."

10. An interview was conducted on 03/30/21 at approximately 11:50 a.m. with the Program Electronic Health Record Manager. When asked if there were any reports in patient #2's clinical record for nursing notes and physician notes documenting and notifying the physician of a staff member hitting or kicking patient #2 or any assessments assessing the patient for getting kicked or hit by a staff member, he concurred there were not any notes or reports.

11. An interview was conducted on 03/30/21 at approximately 12:48 p.m. with the Director of Risk and Quality. When asked when they reported the abuse to the State he stated in part: "CEO sent it ... I sent it to him on the 03/25/21." When asked when the incident was discovered he stated in part: "The Director of HR discovered it on 03/23/21." When asked when the police were notified, he stated in part: "I notified them on 03/24/21. I called the State Police. They didn't know if they had jurisdiction. I did get a call from the office ... from Charleston. ... They came on 03/26/21." When asked who is responsible for documenting the abuse in the patient's chart, he stated in part: "It should be the Nurse Manager on the unit when you have something like that. ... We are taking our employee's confidentiality into consideration. I would expect someone in Nurse Management would do that, but again, how this was discovered, it's a little difficult because it was found by Administration." When asked about a lack of documentation of the patient's abuse by a physician he stated in part: "I think the PA #1 should have had more detail in the assessment."

12. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with BHT #2. When asked what the process is for reporting an incident they stated in part: "If someone got hurt or injured you grab a form and give it to the RN. I don't know what happens after that. ..."

13. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the Interim Director of Nursing. When asked what the expectation is for staff to report abuse, she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and I expect the NM to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

14. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if BHT #3 witnessed the incident, BHT #3 verbalized they did not see what happened. When asked if the patient reported what happened BHT #3 stated in part: "I heard him tell other kids he was kicked. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse BHT #3 stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought the nurse reported it."

15. An interview was conducted on 04/01/21 at approximately 8:13 a.m. with the Medical Director. When notified of patient #2's abuse by staff on 03/20/21 and asked what his expectation is for notifying the physician, he stated in part: "I expect the attending to be notified immediately of what happened to take care of the patient and they should follow up the next day and interview the person of the incident. It's not just about the nurse and they should have assessed the other person (patient). I can see there are issues. I would expect it to be in the notes of the chart." When asked how soon he expects it to be reported he stated in part: "That needs to be reported immediately. If it was not reported then staff could not do the exam." When notified the patient had an exam on 03/25/21 and the assessment did not document any information the patient was abused or was kicked by staff, he stated in part: "They should have documented the results of the exam and the patient was assessed for signs of any injury related to the abuse. I would expect better documentation of assessing the patient and a description of the incident. The attending needs to be notified immediately and the patient assessed for the consequences of the action. ... Things happen and I don't get made aware of it right away. There is fragmentation of information. If the provider doesn't document the information, then the attending doesn't know what happened and nursing doesn't know what happened for continuous care of the patient."

2021-3-024
A. Based on review of medical records, document reviews and staff interviews it was revealed nursing staff failed to provide services according to hospital policies and procedures. This failure was identified in two (2) of thirty (30) medical records reviewed (patient #1 and 4). This failure has the potential to adversely affect all patients.

Findings include:

1. A review of the medical record for patient #1 revealed patient #1 was admitted on 2/27/21 with a diagnosis of behavioral disturbances and for rule out oppositional defiant disorder. On 3/14/21 at 10:52 p.m. Registered Nurse (RN) #1's documentation stated in part: "Client has been oppositional. He was hitting staff. He was placed in a therapeutic hold. Intramuscular (IM) as necessary (PRN) meds were ordered and administered. He began hitting staff again. He was escorted to seclusion. In seclusion room he found small pieces of crayon peer before him had left. He put pieces in nose, ears, and anus. Pieces that could be removed were. He hit staff again and threw a stool at staff. He was secluded. IM PRN meds were ordered and administered. Doctor notified and orders obtained." A review of the administration of medication revealed Ativan two (2) milligrams per 1 milliliter was administered at 4:30 p.m. on 3/14/21 and at 10:30 p.m. on 3/14/31. A review of the medication orders revealed an order that stated, "Order # 312586, Date: 3/14/21 time: 10:33 p.m., Ativan 2mg/1cc injection solution, 1 mg one time only, start time 3/14/21 4:30 p.m. end time: 3/15/21 4:29 p.m. and a second order for 3/14/21 "Order # 312588, Date: 3/14/21 time: 10:33 p.m., Ativan 2mg/1cc injection solution, 1 mg one time only, start time 3/14/21 4:30 p.m. end time: 3/15/21 4:29 p.m." No correct order for the injections of Ativan on 3/14/21 was noted in the medical record.

2. An interview was conducted with the Interim Director of Nursing (IDON) on 3/30/21 at 5:50 p.m. She concurred no appropriate order was obtained for the intramuscular injections given to patient #1 on 3/14/21. When asked when the order is to be entered for all medications, she stated immediately or as soon as possible.

3. A review of the policy titled, "Medication Administration, revised 11/19, stated in part: "Medications will be administered as per physician's order."

4. A review of the medical record for patient #4 revealed patient #4 was admitted for depression and aggression. On 3/13/21 it is documented patient #4 was placed in restraints at 5:56 p.m. Patient #4 was placed in seclusion on 3/14/21 at 6:12 p.m. At 6:23 p.m. seclusion was discontinued. A review of the orders revealed no order for seclusion.

5. A review of the policy titled, "SECLUSION AND RESTRAINT, revised 12/20, stated in part: "Seclusion and Restraint requires a time-limited physician's order."

6. A telephone interview was conducted with the IDON on 4/1/21 at 9:33 a.m. She concurred there was no order for seclusion for 3/13/21. She stated the policy does not state and order for restraints can be taken to the less restrictive on the same order. She did not concur a separate order for seclusion was needed.




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2021-3-026
B. Based on observation, document review and interview the Chief Nursing Officer (CNO) failed to ensure facility nursing staff follow the facility grievance/complaint policies and procedures in the abuse of patient #2. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the Chief Executive Officer (CEO), a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. RN #1 and Behavioral Health Technician (BHT) #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part, "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part, "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

5. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with BHT #2. When asked what the process is for reporting an incident, BHT #2 stated in part: "If someone got hurt or injured you grab a form and give it to the RN. I don't know what happens after that ..."

6. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the IDON. When asked what the expectation is for staff to report abuse, she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and I expect the Nurse Manager (NM) to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

7. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if BHT #3 witnessed the incident, BHT #3 verbalized they did not see what happened. When asked if the patient reported what happened BHT #3 stated in part: "I heard him tell other kids he was kicked. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse BHT #3 stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought the nurse reported it."

C. Based on observation, document review and interview the CNO failed to ensure facility nursing staff follow the facility abuse policy and procedures and in accordance with West Virginia State law. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the CEO, a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. RN #1 and BHT #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part, "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part, "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

5. A review of WV State Code §49-2-803 states in part: "Persons mandated to report suspected abuse and neglect; requirements. (a) Any medical, dental, or mental health professional, Christian Science practitioner, religious healer, school teacher or other school personnel, social service worker, child care or foster care worker, emergency medical services personnel, peace officer or law-enforcement official, humane officer, member of the clergy, circuit court judge, family court judge, employee of the Division of Juvenile Services, magistrate, youth camp administrator or counselor, employee, coach or volunteer of an entity that provides organized activities for children, or commercial film or photographic print processor who has reasonable cause to suspect that a child is neglected or abused, including sexual abuse or sexual assault, or observes the child being subjected to conditions that are likely to result in abuse or neglect shall immediately, and not more than twenty-four (24) hours after suspecting this abuse or neglect, report the circumstances to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse or sexual abuse or sexual assault, the reporter shall also immediately report to the State Police and any law-enforcement agency having jurisdiction to investigate the complaint."

6. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

7. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse, she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO ... and we reviewed the video together. ... On 03/24/2, I called RN #1, with NM #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to Face Timed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had someone call back and the police came on 03/26/21." When asked if the Interim Director of Nursing was notified, she stated in part: "We are reporting to the nursing board. This is done by NM #1 or the IDON. They have been appraised of everything on 03/24/21." When asked when they will be reporting the nurse to the RN Board of WV, she stated in part: "The IDON will be filing it tomorrow to the WV Board of Nursing."

8. An interview was conducted on 03/30/21 at approximately 11:21 a.m. with Physician Assistant (PA) #1. When asked if she was notified if patient #2 was abused on 03/20/21 by a staff member, she stated in part: "I was requested by administration to examine him on 03/25/21. ... I asked him (patient) if he had gotten hit or kicked, and he denied it. I examined him and he had no issues. I was notified when the Director of Risk and Quality came to me. I did not see the video, and no one said anything. I did look at his head and, in his hair, and didn't see anything. I don't know if the psychiatrist was notified."

9. An interview was conducted on 03/30/21 at approximately 11:50 a.m. with the Program Electronic Health Record Manager. When asked if there were any reports in patient #2's clinical record for nursing notes and physician notes documenting and notifying the physician of a staff member hitting or kicking patient #2 or any assessments assessing the patient for getting kicked or hit by a staff member, he concurred there were not any notes or reports.

10. An interview was conducted on 03/30/21 at approximately 12:48 p.m. with the Director of Risk and Quality. When asked when they reported the abuse to the State he stated in part: "CEO sent it ... I sent it to him on the 03/25/21." When asked when the incident was discovered he stated in part: "The Director of HR discovered it on 03/23/21." When asked when the police were notified, he stated in part: "I notified them on 03/24/21. I called the State Police. They didn't know if they had jurisdiction. I did get a call from the office ... from Charleston. ... They came on 03/26/21." When asked who is responsible for documenting the abuse in the patient's chart, he stated in part: "It should be the NM on the unit when you have something like that. ... We are taking our employee's confidentiality into consideration. I would expect someone in Nurse Management would do that, but again, how this was discovered, it's a little difficult because it was found by Administration." When asked about a lack of documentation of the patient's abuse by a physician he stated in part: "I think the PA #1 should have had more detail in the assessment."

11. An interview was conducted on 03/30/21 at approximately 1:51 p.m. with BHT #2. When asked what the process is for reporting an incident BHT #2 stated in part: "If someone got hurt or injured you grab a form and give it to the RN. I don't know what happens after that. ..."

12. An interview was conducted on 03/30/01 at approximately 2:01 p.m. with the Interim Director of Nursing. When asked what the expectation is for staff to report abuse, she stated in part: "If another employee witnessed abuse, they would contact the Nurse Supervisor and escalate it up the chain and I expect the NM to be notified. We have an incident report that does have an abuse allegation to provide information. ... We have a process map and report all allegations. ... It has to be reported within twenty-four (24) hours."

13. An interview was conducted on 03/30/21 at approximately 4:22 p.m. with BHT #3. When asked if BHT #3 witnessed the incident, BHT #3 verbalized they did not see what happened. When asked if the patient reported what happened BHT #3 stated in part: "I heard him tell other kids he was kicked. I didn't report it. The RN reported it after it happened." When asked what the process is to report abuse BHT #3 stated in part: "We report it to the Charge Nurse or supervisor." When asked if they should have reported the abuse BHT #3 stated in part: "I should have reported it, but he was just talking. I think I might have said to not talk about what happened. Thinking about it now, I should have reported it, but I thought the nurse reported it."

14. An interview was conducted on 04/01/21 at approximately 8:13 a.m. with the Medical Director. When notified of patient #2's abuse by staff on 03/20/21 and asked what his expectation is for notifying the physician, he stated in part: "I expect the attending to be notified immediately of what happened to take care of the patient and they should follow up the next day and interview the person of the incident. It's not just about the nurse and they should have assessed the other person (patient). I can see there are issues. I would expect it to be in the notes of the chart." When asked how soon he expects it to be reported he stated in part: "That needs to be reported immediately. If it was not reported then staff could not do the exam." When notified the patient had an exam on 03/25/21 and the assessment did not document any information the patient was abused or was kicked by staff, he stated in part: "They should have documented the results of the exam and the patient was assessed for signs of any injury related to the abuse. I would expect better documentation of assessing the patient and a description of the incident. The attending needs to be notified immediately and the patient assessed for the consequences of the action. ... Things happen and I don't get made aware of it right away. There is fragmentation of information. If the provider doesn't document the information, then the attending doesn't know what happened and nursing doesn't know what happened for continuous care of the patient."


D. Based on video review, clinical record review, document review and staff interview it was determined the IDON failed to ensure nursing staff followed policy and procedures to complete an incident report and notify the medical provider immediately when suspecting an employee had abused a patient (patient #2). This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. In the presence of the CEO, a review of video footage was conducted on 03/29/21 at approximately 12:10 a.m. The video review of the hallway of Unit 2 East dated 03/20/21 at approximately 7:57 a.m. revealed patient #2 was bent over into the breakfast cart located in the hallway just outside the dayroom. RN #1 and BHT #3 were walking toward the food cart and saw the patient in the cart. The patient was interrupted by the staff and stood up from the cart with his arms and hands by his side. RN #1 grabbed the patient by his shirt collar and pulled him away from the cart, the patient lost balance and fell to the floor and the RN continued to pull the patient by the shirt collar sliding him along the floor further from the cart. The BHT turned and was walking around behind the cart going into the dayroom which prevented their view of the following interaction between the RN and patient. At the same time, the patient and RN appeared to have a brief verbal exchange and the patient reached out with his right arm/hand and appeared to strike the RN in the groin area. The RN appeared to have reached out and grabbed the patient's hand/wrist area. She then lifted her right leg, impacted into the patient appearing to hit the patient's head with her knee. The patient fell over onto his right side from his sitting position into a lying position on the floor. He remained there for approximately one (1) minute. At approximately 7:58 a.m. BHT #2 walked out of the dayroom and stood against the wall by the patient. The RN took a few steps back and then walked toward and stepped over the patient lying on the floor and started walking down the hall. The patient sat up and remained sitting on the floor. The RN exited the hallway through a doorway. At approximately 7:59 a.m. the patient stood up and walked into the dayroom and sat down at a table with three (3) other patients and began watching TV.

2. A review of facility policy, "Grievance and Complaint Process," revised 07/24/19, states in part, "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, "Abuse Reporting - Adult/Child and Documentation," revised 04/2018, states in part, "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

4. A review of facility policy, "Incident Reporting and Severity Classification - Acute," approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

5. A review of patient #2's clinical record from 01/30/21 through 03/29/21 revealed there was no documentation of nursing staff notifying a physician of suspected abuse occurring to the patient by staff and no provider documentation of an assessment evaluating the patient for abuse. A "History of Present Illness (HPI)" physical report was documented on 03/25/21 at 4:41 p.m. by Physician Assistant (PA) #1, revealed the assessment does not document the patient was being examined for abuse, what abuse occurred and if there were or were not any signs of injury related to abuse.

6. A review of facility policy, "Nursing Assessment/Reassessment," revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. A review of "Highland Hospital Medical Staff Rules and Regulations," approved 03/29/26, stated in part: "Progress notes shall be entered into the medical record daily by a Physician, or his / her designee. At a minimum, the progress note shall describe treatment interventions, the rationale for the intervention, and the patient's response to these interventions. Progress notes should be recorded at the time of observation and contain enough substance and detail to facilitate continuity of care. Notes made by a designee shall be initialed by the attending physician. The physician shall enter into the medical record a progress note, at a minimum, weekly for Partial Hospitalization and Subacute patients."

8. An interview was conducted on 03/29/21 at approximately 4:22 p.m. with the Director of Human Resources (HR). When asked when she found out about the abuse, she stated in part: "RN #1 reported she was injured from a patient hitting her. ... I was watching the video ... I viewed it on 03/23/21. An employee injury report was received on 03/22/21. Her last day worked was 03/20/21. ... She was out on Worker's Compensation. I had no idea anything happened. ... I went immediately to the Director of Risk and Quality and the CEO ... and we reviewed the video together. ... On 03/24/2, I called RN #1, with NM #1. We face timed her at 6:30 p.m. when we were able to reach the employee for an interview. ... My recommendation was termination. I have to get corporate to approve the termination. ... On 03/26/21 we tried to call her, texted her and tried to Face Timed her for termination. She didn't respond so I mailed out a termination letter ... We are reporting it to the nursing board. ... We reported it to the cops. The Director of Risk and Quality did it. He called on the Wednesday 03/24/21 or Thursday 03/25/21. ... They had