HospitalInspections.org

Based on 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, document restraints per hospital policy and follow their complaint policy for abuse when the patient became agitated. These findings have the potential for all patients to be at risk for abuse and injury. (See tags A 144, A 145, A 167, A 178 and A 179).

A. Noncompliance: The facility failed to ensure patient #1 was free from all forms of abuse or harassment, failed to complete and submit an Adult Protective Services Mandatory report in accordance with applicable West Virginia State law and failed to remove all staff involved in the alleged abuse of the care of patient #1. This failure was identified in one (1) out of thirty (30) patient record reviews.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: As a mandatory reporter, the facility is not reporting incidences of employee abuse or suspected abuse to the State Adult Protective Services Department. All staff involved in suspected aggressive actions of the patient were not removed pending investigation. This failure has the potential for all patients admitted to the unit to be at risk for abuse and injury.

C. Need for Immediate action: The facility needs to correct their processes to implement reporting any Adult Protective Services allegations of potential abuse and follow facility policy to ensure they remove all staff involved in the potential abuse pending their investigation to protect patients from harm. 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 11/17/20 at 8:15 p.m.

A. Based on observation of video recordings, document review and staff interviews it was determined the facility failed to remove all staff suspected in the alleged abuse of patient #1 from the schedule until they completed their investigation. 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. A review of video footage in the hallway of Unit #3 West dated 11/08/20 at approximately 10:05 a.m. revealed after a discussion with patient #1, who appeared to be agitated, Registered Nurse (RN) #1, who was standing in front of the medication cart, grabbed patient #1's right arm. Mental Health Technician (MHT) #3, next to the medication cart near the patient, grabbed his left arm and proceeded to turn the patient and slide him down the hall with his feet dragging behind him. A third staff member was following behind the patient.

2. A review of video footage of the entrance to the seclusion room of Unit #3 West dated 11/08/20 at approximately 10:30 a.m. revealed two (2) staff members holding the patient's arms, walking patient #1 backwards into the seclusion room, laying the patient on the floor on his back and leaving the room.

3. A review of facility policy, "Identification/Reporting of Abuse," revised 06/2017, states in part: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

4. A review of the facility investigation report documented from 11/10/20 through 11/16/20 revealed staff identified in the investigation included one (1) RN (RN #1) and five (5) MHTs (MHT #1, 2, 3, 4 and 5).

5. An interview with the Chief Nursing Officer (CNO) was conducted on 11/16/20 at approximately 2:30 p.m. When requested to review the investigation, she verbalized she is still completing the investigation.

6. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and she said to speak to the Manager of that unit. I reported it the next day to Nurse Manager #1 on 11/09/20."

7. An interview with the CNO was conducted on 11/16/20 at approximately 3:07 p.m. When asked to interview the MHT staff members, all staff were scheduled and interviewed in person and by telephone during the survey onsite during and after their scheduled shifts.

8. An interview with the CNO and Chief Executive Officer (CEO) was conducted on 11/17/20 at approximately 3:15 p.m. When discussing if all staff involved in the complaint were taken off the schedule, they verbalized staff were following instructions from RN #1 and were not taken off the schedule.

B. Based on document review and staff interviews it was determined the CNO failed to ensure nursing staff followed policy and procedure to complete an incident report and notify the attending physician immediately when suspecting an employee had abused a patient (patient #1). 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. A review of patient #1's clinical record from 11/08/20 through 11/09/20 revealed a lack of documentation notifying a physician of suspected abuse by staff.

2. A review of the incident log revealed there was not an incident report for suspected abuse by staff for patient #1.

3. A review of facility policy "Identification/Reporting of Abuse," revision date: 06/2017, states in part: "An Occurrence report will be completed by the Charge Nurse and given to the Program Director/Nursing Supervisor, who will notify the attending physician immediately."

4. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked what happened with patient #1 on 11/08/20 she stated in part, "That day I was supervising and working the floor. I was called and asked if it was ok to put a patient in seclusion. I told him he was the nurse and had to use his best clinical judgement. That afternoon I received the paperwork and saw who it was ... I didn't feel there was a need to put the patient in seclusion. He is usually redirectable. ..." When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and said to speak to the manager of that unit. I reported it the next day to Nurse Manager #1 on 11/09/20." When asked if she documented in the Quality Registered Nurse face to face assessment she stated in part, "I put in there. It could have been prevented. We can suggest they (patients) wear a mask but can't force them."

5. An interview with the Program Director was conducted on 11/17/12 at approximately 12:56 p.m. When asked what happened with patient #1 on 11/08/20 she stated in part, "I get a copy of the shift report ... It alerted there was a restraint on my unit and I have a video to review and I had some concerns ... I reported it to his supervisor, the Chief Nursing Officer (CNO). She did review it and agreed with me, spoke to Risk Management and made a report, spoke with the CEO and Human Resources and recommended termination."

6. An interview was conducted with Nurse Manager #1 on 11/17/20 at approximately 1:30 p.m. When asked if she completed the incident forms she stated in part, "I asked her (Nurse Supervisor #1) if she filled out the paperwork and notified the CNO and the Program Director. I didn't fill out the forms, it is the RN or Supervisor's responsibility to complete the forms." When asked if she reported it to Adult Protective Services (APS), she verbalized she did not complete the APS and stated in part, "The CNO took care of it. It was reported to the Office of Health Facility Licensure and Certification (OHFLAC)."

7. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know."

8. An interview with Nurse Manager #1 was conducted on 11/18/20 at approximately 11:15 a.m. When asked if the physician was notified to see the patient after the incident she stated in part, "The patient was seen by Nurse Practitioner #2 at 5:16 p.m. on 11/09/20.

9. An interview with Nurse Practitioner #2 was conducted on 11/18/20 at approximately 11:30 a.m. When asked if she had been notified of an improper Therapeutic Crisis Intervention (TCI) Hold for patient #1 occurring on 11/08/20 she stated in part, "I did not know he had improper TCI techniques. ... I never had anyone call when the patient was found to have an improper hold. I knew he had been in a hold and saw him. I just did my normal visit."

10. An interview with the Performance Improvement Director was conducted on 11/18/20 at approximately 12:22 p.m. When asked if an incident was filed for patient #1 after the video was reviewed she stated in part, "No incident was filed, only for the restraint."

A. Based on document review and interview the facility failed to ensure patient #1 was free from all forms of abuse or harassment. The facility failed to complete and submit an Adult Protective Services (APS) 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. A review of the facility investigation conducted from 11/10/20 through 11/16/20 revealed the facility did not complete and submit an APS Mandatory Reporting Form to the APS Unit.

2. A review of facility policy, "Identification/Reporting of Abuse," revised 06/2017, states in part: "All cases of known or suspected abuse and/or neglect of children or incapacitated adults occurring outside the facility and any cases of suspected abuse or neglect of a patient within the hospital or its programs will be reported to the appropriate authorities in accordance with West Virginia law."

3. A review of "West Virginia Code §9-6-9 Mandatory Reporting of Incidences of Abuse, Neglect, Financial Exploitation, or Emergency Situation" states in part: "(a) If any medical, dental, or mental health professional, ... or any employee of any nursing home or other residential facility, has reasonable cause to believe that a vulnerable adult or facility resident is or has been neglected, abused, financially exploited or placed in an emergency situation, or if such person observes a vulnerable adult or facility resident being subjected to conditions that are likely to result in abuse, neglect, financial exploitation, or an emergency situation, the person shall immediately report the circumstances pursuant to the provisions of §9-6-11 of this code: Provided, that nothing in this article is intended to prevent individuals from reporting on their own behalf."

4. A review of "West Virginia Code §9-6-11 Reporting Procedures" states in part: "a) A report of neglect, abuse, or financial exploitation of a vulnerable adult or facility resident, or of an emergency situation involving such an adult, shall be made immediately, and not more than 48 hours after suspecting abuse, neglect or financial exploitation, to the department's adult protective services agency by a method established by the department."

5. An interview with the Chief Nursing Officer (CNO) was conducted on 11/16/20 at approximately 2:30 p.m. When asked if she reported the alleged abuse to the APS department she stated in part, "I was told I didn't need to contact APS per the Risk Compliance Officer."

6. A telephone interview with the Risk Compliance Officer was conducted on 11/17/20 at approximately 2:27 p.m. When asked if they report alleged abuse by employees to APS she stated in part, "We never called APS, only called the Office of Health Facility Licensure and Certification (OHFLAC)."

B. Based on observation of video recordings, document review and staff interviews it was determined the facility failed to remove all staff suspected in the alleged abuse of patient #1 from the schedule until they completed their investigation. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to ensure the patient was protected from all forms of abuse has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of video footage in the hallway of Unit #3 West dated 11/08/20 at approximately 10:05 a.m. revealed after a discussion with patient #1, who appeared to be agitated, Registered Nurse (RN) #1, who was standing in front of the medication cart, grabbed patient #1's right arm. Mental Health Technician (MHT) #3, next to the medication cart near the patient, grabbed his left arm and proceeded to turn the patient and slide him down the hall with his feet dragging behind him. A third staff member was following behind the patient.

2. A review of video footage of the entrance to the seclusion room of Unit #3 West dated 11/08/20 at approximately 10:30 a.m. revealed two (2) staff members holding the patient's arms, walking patient #1 backwards into the seclusion room, laying the patient on the floor on his back and leaving the room.

3. A review of facility policy, "Identification/Reporting of Abuse," revised 06/2017, states in part: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

4. A review of the facility investigation report documented from 11/10/20 through 11/16/20 revealed staff identified in the investigation included one (1) RN (RN #1) and five (5) MHTs (MHT #1, 2, 3, 4 and 5).

5. An interview with the Chief Nursing Officer (CNO) was conducted on 11/16/20 at approximately 2:30 p.m. When requested to review the investigation, she verbalized she is still completing the investigation.

6. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and she said to speak to the Manager of that unit. I reported it the next day to Nurse Manager #1 on 11/09/20."

7. An interview with the CNO was conducted on 11/16/20 at approximately 3:07 p.m. When asked to interview the MHT staff members, all staff were scheduled and interviewed in person and by telephone during the survey onsite during and after their scheduled shifts.

8. An interview with the CNO and Chief Executive Officer (CEO) was conducted on 11/17/20 at approximately 3:15 p.m. When discussing if all staff involved in the complaint were taken off the schedule, they verbalized staff were following instructions from RN #1 and were not taken off the schedule.

Based on clinical record review, document review and interviews the facility failed to ensure a Qualified Registered Nurse (QRN), Nurse Supervisor #1, conducted a one (1) hour face to face (F2F) assessment of patient #1 in seclusion or restraints following facility policy and procedures and in accordance with State law. This failure was identified in one (1) out of thirty (30) clinical records reviewed. This failure to ensure the patient was assessed within one (1) hour after implementation of restraints has the potential for all patients to be at risk for abuse, neglect and injury.

Findings include:

1. A clinical record review of patient #1 revealed a physical hold restraint was implemented on 11/08/20 at 9:08 a.m., received mediations by intramuscular injection at 9:15 a.m., then placed into seclusion at 9:29 a.m. The QRN, Nurse Supervisor #1, conducted a one (1) hour F2F assessment on 11/08/20 at 5:01 p.m.

2. A review of facility policy, "Seclusion/Restraint/Physical Hold," review date 07/2019, states in part: "A Physician, Qualified RN (QRN) or other Licensed Independent Practitioner allowed by law and scope of practice-conducts an in-person, face to face assessment of the patient in S/R (seclusion/restraint) within one (1) hour of initiation and documents findings on the One Hour Face to Face Evaluation."

3. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if patient #1 had a F2F evaluation she stated in part, "The patient is required to have a F2F by the QRN ... I was supposed to but couldn't leave the unit to do a F2F. It's supposed to be done within an hour."

4. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know." When asked if she would conduct the face to face evaluation for patient #1, she stated in part, "I would not have done the F2F because I wasn't aware of what happened. The nurse that had the call would complete it."

Based on clinical record review, document review and interviews the facility failed to ensure a Qualified Registered Nurse (QRN), Nurse Supervisor #1, conducted a face to face (F2F) assessment of patient #1 within one (1) hour after initiation of restraint, administration of medication and seclusion to manage violent behavior that jeopardizes the immediate safety of the patient, a staff member or others. This failure was identified in one (1) out of thirty (30) clinical records reviewed. This failure to ensure the patient was assessed within one (1) hour after implementation of restraints has the potential for all patients to be at risk for abuse, neglect and injury.

Findings include:

1. A clinical record review of patient #1 revealed a physical hold restraint was implemented on 11/08/20 at 9:08 a.m., received mediations by intramuscular injection at 9:15 a.m., then placed into seclusion at 9:29 a.m. The QRN, Nurse Supervisor #1, conducted a one (1) hour F2F assessment on 11/08/20 at 5:01 p.m.

2. A review of facility policy, "Seclusion/Restraint/Physical Hold," review date 07/2019, states in part: "A Physician, Qualified RN (QRN) or other Licensed Independent Practitioner allowed by law and scope of practice-conducts an in-person, face to face assessment of the patient in S/R (seclusion/restraint) within one (1) hour of initiation and documents findings on the One Hour Face to Face Evaluation."

3. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if patient #1 had a F2F evaluation she stated in part, "The patient is required to have a F2F by the QRN ... I was supposed to but couldn't leave the unit to do a F2F. It's supposed to be done within an hour."

4. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know." When asked if she would conduct the face to face evaluation for patient #1, she stated in part, "I would not have done the F2F because I wasn't aware of what happened. The nurse that had the call would complete it."

Based on clinical record review, document review and interviews the facility failed to ensure a Qualified Registered Nurse (QRN), Nurse Supervisor #1, conducted a face to face (F2F) assessment of patient #1 within one (1) hour after initiation of restraint, administration of medication and seclusion to manage violent behavior that jeopardizes the immediate safety of the patient, a staff member or others. This failure was identified in one (1) out of thirty (30) clinical records reviewed. This failure to ensure the patient was assessed within one (1) hour after implementation of restraints has the potential for all patients to be at risk for abuse, neglect and injury.

Findings include:

1. A clinical record review of patient #1 revealed a physical hold restraint was implemented on 11/08/20 at 9:08 a.m., received mediations by intramuscular injection at 9:15 a.m., then placed into seclusion at 9:29 a.m. The QRN, Nurse Supervisor #1, conducted a one (1) hour F2F assessment on 11/08/20 at 5:01 p.m.

2. A review of facility policy, "Seclusion/Restraint/Physical Hold," review date 07/2019, states in part: "A Physician, Qualified RN (QRN) or other Licensed Independent Practitioner allowed by law and scope of practice-conducts an in-person, face to face assessment of the patient in S/R (seclusion/restraint) within one (1) hour of initiation and documents findings on the One Hour Face to Face Evaluation."

3. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if patient #1 had a F2F evaluation she stated in part, "The patient is required to have a F2F by the QRN ... I was supposed to but couldn't leave the unit to do a F2F. It's supposed to be done within an hour."

4. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know." When asked if she would conduct the face to face evaluation for patient #1, she stated in part, "I would not have done the F2F because I wasn't aware of what happened. The nurse that had the call would complete it."

Based on 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 #1 and follow their reporting of abuse and restraint polices and procedures. 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 Chief Nursing Officer failed to ensure an Adult Protective Services (APS) Mandatory report was submitted in accordance with applicable West Virginia State law and ensure Nurse Manager #1 supervise and evaluate nursing staff and remove all staff involved in the alleged abuse of patient #1. This failure was identified in one (1) out of thirty (30) patient record reviews.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: As a mandatory reporter the facility is not reporting incidences of employee abuse or suspected abuse to the State APS Department. All staff involved in suspected aggressive actions of the patient were not removed pending investigation. This failure has the potential for all patients admitted to the unit to be at risk for abuse and injury.

C. Need for Immediate action: The facility needs to correct their processes to implement reporting any APS allegations of potential abuse and follow facility policy to ensure they remove all staff involved in the potential abuse pending their investigation to protect patients from harm. 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 11/17/20 at 8:15 p.m.

A. Based on document review and interview the Chief Nursing Officer failed to ensure an Adult Protective Services (APS) Mandatory report was submitted in accordance with applicable West Virginia State law. 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. A review of the facility investigation conducted from 11/10/20 through 11/16/20 revealed the facility did not complete and submit an APS Mandatory Reporting form to the APS Unit.

2. A review of facility policy "Identification/Reporting of Abuse," revised 06/2017, states in part: "All cases of known or suspected abuse and/or neglect of children or incapacitated adults occurring outside the facility and any cases of suspected abuse or neglect of a patient within the hospital or its programs will be reported to the appropriate authorities in accordance with West Virginia law."

3. A review of "West Virginia Code §9-6-9 Mandatory Reporting of Incidences of Abuse, Neglect, Financial Exploitation, or Emergency Situation" states in part: "(a) If any medical, dental, or mental health professional, ... or any employee of any nursing home or other residential facility, has reasonable cause to believe that a vulnerable adult or facility resident is or has been neglected, abused, financially exploited or placed in an emergency situation, or if such person observes a vulnerable adult or facility resident being subjected to conditions that are likely to result in abuse, neglect, financial exploitation, or an emergency situation, the person shall immediately report the circumstances pursuant to the provisions of §9-6-11 of this code: Provided, that nothing in this article is intended to prevent individuals from reporting on their own behalf.

4. A review of "West Virginia Code §9-6-11 Reporting Procedures" states in part: "a) A report of neglect, abuse, or financial exploitation of a vulnerable adult or facility resident, or of an emergency situation involving such an adult, shall be made immediately, and not more than 48 hours after suspecting abuse, neglect or financial exploitation, to the department's adult protective services agency by a method established by the department."

5. An interview with the Chief Nursing Officer (CNO) was conducted on 11/16/20 at approximately 2:30 p.m. When asked if she reported the alleged abuse to the APS department she stated in part, "I was told I didn't need to contact APS per the Risk Compliance Officer."

6. A telephone interview with the Risk Compliance Officer was conducted on 11/17/20 at approximately 2:27 p.m. When asked if they report alleged abuse by employees to APS she stated in part, "We never called APS, only called the Office of Health Facility Licensure and Certification (OHFLAC)."

B. Based on document review and interview the CNO failed to ensure Nurse Manager #1 removed all staff involved in the alleged abuse of the care of patient #1. 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. A review of video footage in the hallway of Unit #3 West dated 11/08/20 at approximately 10:05 a.m. revealed after a discussion with patient #1, who appeared to be agitated, Registered Nurse (RN) #1, who was standing in front of the medication cart, grabbed patient #1's right arm. Mental Health Technician (MHT) #3, next to the medication cart near the patient, grabbed his left arm and proceeded to turn the patient and slide him down the hall with his feet dragging behind him. A third staff member was following behind the patient.

2. A review of video footage of the entrance to the seclusion room of Unit #3 West dated 11/08/20 at approximately 10:30 a.m. revealed two (2) staff members holding the patient's arms, walking patient #1 backwards into the seclusion room, laying the patient on the floor on his back and leaving the room.

3. A review of facility policy, "Identification/Reporting of Abuse," revised 06/2017, states in part: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

4. A review of the facility investigation report documented from 11/10/20 through 11/16/20 revealed staff identified in the investigation included one (1) RN (RN #1) and five (5) MHTs (MHT #1, 2, 3, 4 and 5).

5. An interview with the Chief Nursing Officer (CNO) was conducted on 11/16/20 at approximately 2:30 p.m. When requested to review the investigation, she verbalized she is still completing the investigation.

6. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and she said to speak to the Manager of that unit. I reported it the next day to Nurse Manager #1 on 11/09/20."

7. An interview with the CNO was conducted on 11/16/20 at approximately 3:07 p.m. When asked to interview the MHT staff members, all staff were scheduled and interviewed in person and by telephone during the survey onsite during and after their scheduled shifts.

8. An interview with the CNO and Chief Executive Officer (CEO) was conducted on 11/17/20 at approximately 3:15 p.m. When discussing if all staff involved in the complaint were taken off the schedule, they verbalized staff were following instructions from RN #1 and were not taken off the schedule.

A. Based on document review and interview the Chief Nursing Officer (CNO) failed to ensure an Adult Protective Services (APS) Mandatory report was submitted in accordance with applicable West Virginia State law. 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. A review of the facility investigation conducted from 11/10/20 through 11/16/20 revealed the facility did not complete and submit an APS Mandatory Reporting form to the APS Unit.

2. A review of facility policy "Identification/Reporting of Abuse," revised 06/2017, states in part: "All cases of known or suspected abuse and/or neglect of children or incapacitated adults occurring outside the facility and any cases of suspected abuse or neglect of a patient within the hospital or its programs will be reported to the appropriate authorities in accordance with West Virginia law."

3. A review of "West Virginia Code §9-6-9 Mandatory Reporting of Incidences of Abuse, Neglect, Financial Exploitation, or Emergency Situation" states in part: "(a) If any medical, dental, or mental health professional, ... or any employee of any nursing home or other residential facility, has reasonable cause to believe that a vulnerable adult or facility resident is or has been neglected, abused, financially exploited or placed in an emergency situation, or if such person observes a vulnerable adult or facility resident being subjected to conditions that are likely to result in abuse, neglect, financial exploitation, or an emergency situation, the person shall immediately report the circumstances pursuant to the provisions of §9-6-11 of this code: Provided, that nothing in this article is intended to prevent individuals from reporting on their own behalf.

4. A review of "West Virginia Code §9-6-11 Reporting Procedures" states in part: "a) A report of neglect, abuse, or financial exploitation of a vulnerable adult or facility resident, or of an emergency situation involving such an adult, shall be made immediately, and not more than 48 hours after suspecting abuse, neglect or financial exploitation, to the department's adult protective services agency by a method established by the department."

5. An interview with the CNO was conducted on 11/16/20 at approximately 2:30 p.m. When asked if she reported the alleged abuse to the APS department she stated in part, "I was told I didn't need to contact APS per the Risk Compliance Officer."

6. A telephone interview with the Risk Compliance Officer was conducted on 11/17/20 at approximately 2:27 p.m. When asked if they report alleged abuse by employees to APS she stated in part, "We never called APS, only called the Office of Health Facility Licensure and Certification (OHFLAC)."

B. Based on document review and interview the CNO failed to ensure Nurse Manager (NM) #1 remove all staff involved in the alleged abuse of the care of patient #1. 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. A review of video footage in the hallway of Unit #3 West dated 11/08/20 at approximately 10:05 a.m. revealed after a discussion with patient #1, who appeared to be agitated, Registered Nurse (RN) #1, who was standing in front of the medication cart, grabbed patient #1's right arm. Mental Health Technician (MHT) #3, next to the medication cart near the patient, grabbed his left arm and proceeded to turn the patient and slide him down the hall with his feet dragging behind him. A third staff member was following behind the patient.

2. A review of video footage of the entrance to the seclusion room of Unit #3 West dated 11/08/20 at approximately 10:30 a.m. revealed two (2) staff members holding the patient's arms, walking patient #1 backwards into the seclusion room, laying the patient on the floor on his back and leaving the room.

3. A review of facility policy, "Identification/Reporting of Abuse," revised 06/2017, states in part: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

4. A review of the facility investigation report documented from 11/10/20 through 11/16/20 revealed staff identified in the investigation included one (1) RN (RN #1) and five (5) MHTs (MHT #1, 2, 3, 4 and 5).

5. An interview with the CNO was conducted on 11/16/20 at approximately 2:30 p.m. When requested to review the investigation, she verbalized she is still completing the investigation.

6. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and she said to speak to the Manager of that unit. I reported it the next day to NM #1 on 11/09/20."

7. An interview with the CNO was conducted on 11/16/20 at approximately 3:07 p.m. When asked to interview the MHT staff members, all staff were scheduled and interviewed in person and by telephone during the survey onsite during and after their scheduled shifts.

8. An interview with the CNO and Chief Executive Officer (CEO) was conducted on 11/17/20 at approximately 3:15 p.m. When discussing if all staff involved in the complaint were taken off the schedule, they verbalized staff were following instructions from RN #1 and were not taken off the schedule.

C. Based on document review and staff interviews it was determined the CNO failed to ensure nursing staff followed policy and procedures to complete an incident report and notify the attending physician immediately when suspecting an employee had abused a patient (patient #1). 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. A review of patient #1's clinical record from 11/08/20 through 11/09/20 revealed a lack of documentation notifying a physician of suspected abuse by staff.

2. A review of the incident log revealed there was not an incident report for suspected abuse by staff for patient #1.

3. A review of facility policy, "Identification/Reporting of Abuse," revision date 06/2017, states in part: "An Occurrence report will be completed by the Charge Nurse and given to the Program Director/Nursing Supervisor, who will notify the attending physician immediately."

4. An interview with Nurse Supervisor #1 was conducted on 11/17/20 at approximately 12:15 p.m. When asked what happened with patient #1 on 11/08/20 she stated in part, "That day I was supervising and working the floor. I was called and asked if it was ok to put a patient in seclusion. I told him he was the nurse and had to use his best clinical judgement. That afternoon I received the paperwork and saw who it was ... I didn't feel there was a need to put the patient in seclusion. He is usually redirectable. ..." When asked if she reported it she stated in part, "I talked to Nurse Supervisor #2. She came in at 1:00 p.m. and said to speak to the manager of that unit. I reported it the next day to NM #1 on 11/09/20." When asked if she documented in the Quality Registered Nurse (QRN) face to face assessment she stated in part, "I put in there. It could have been prevented. We can suggest they (patients) wear a mask but can't force them."

5. An interview with the Program Director was conducted on 11/17/12 at approximately 12:56 p.m. When asked what happened with patient #1 on 11/08/20 she stated in part, "I get a copy of the shift report ... It alerted there was a restraint on my unit and I have a video to review and I had some concerns ... I reported it to his supervisor, the CNO. She did review it and agreed with me, spoke to Risk Management and made a report, spoke with the CEO and Human Resources and recommended termination."

6. An interview was conducted with NM #1 on 11/17/20 at approximately 1:30 p.m. When asked if she completed the incident forms she stated in part, "I asked her (Nurse Supervisor #1) if she filled out the paperwork and notified the CNO and the Program Director. I didn't fill out the forms, it is the RN or Supervisor's responsibility to complete the forms." When asked if she reported it to APS, she verbalized she did not complete the APS and stated in part, "The CNO took care of it. It was reported to the OHFLAC."

7. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know."

8. An interview with NM #1 was conducted on 11/18/20 at approximately 11:15 a.m. When asked if the physician was notified to see the patient after the incident she stated in part, "The patient was seen by Nurse Practitioner (NP) #2 at 5:16 p.m. on 11/09/20.

9. An interview with NP #2 was conducted on 11/18/20 at approximately 11:30 a.m. When asked if she had been notified of an improver Therapeutic Crisis Intervention (TCI) Hold for patient #1 occurring on 11/08/20 she stated in part, "I did not know he had improper TCI techniques. ... I never had anyone call when the patient was found to have an improper hold. I knew he had been in a hold and saw him. I just did my normal visit."

10. An interview with the Performance Improvement Director was conducted on 11/18/20 at approximately 12:22 p.m. When asked if an incident was filed for patient #1 after the video was reviewed she stated in part, "No incident was filed, only for the restraint."

D. Based on clinical record review, document review and interviews the CNO failed to ensure a QRN, Nurse Supervisor #1, followed policy and procedures and conduct a face to face (F2F) assessment of patient #1 within one (1) hour after initiation of restraint, administration of medication and seclusion to manage violent behavior that jeopardizes the immediate safety of the patient, a staff member or others. This failure was identified in one (1) out of thirty (30) clinical records reviewed. This failure to ensure the patient was assessed within one (1) hour after implementation of restraints has the potential for all patients to be at risk for abuse, neglect and injury.

Findings include:

1. A clinical record review of patient #1 revealed a physical hold restraint was implemented on 11/08/20 at 9:08 a.m., received mediations by intramuscular injection at 9:15 a.m. then placed into seclusion at 9:29 a.m. The QRN, Nurse Supervisor #1, conducted a one (1) hour F2F assessment on 11/08/20 at 5:01 p.m.

2. A review of facility policy, "Seclusion/Restraint/Physical Hold," review date 07/2019, states in part: "A Physician, Qualified RN (QRN), or other Licensed Independent Practitioner allowed by law and scope of practice-conducts an in-person, face to face assessment of the patient in S/R (seclusion/restraint) within one (1) hour of initiation and documents findings on the One Hour Face to Face Evaluation."

3. An interview was conducted with Nurse Supervisor #1 on 11/17/20 at approximately 12:15 p.m. When asked if patient #1 had a F2F evaluation she stated in part, "The patient is required to have a F2F by the QRN ... I was supposed to but couldn't leave the unit to do a F2F. It's supposed to be done with an hour."

4. An interview with Nurse Supervisor #2 was conducted on 11/17/20 at approximately 4:51 p.m. When asked if she was notified of the restraint with patient #1 on 11/08/20 she stated in part, "I took over supervising duties at 3:00 p.m. ... Nurse Supervisor #1 was taking care of patients. ... She called me and told me there was a restraint and was uncomfortable with it ... I told her that I haven't seen what happened and if you don't agree then document it and let the Program Director know." When asked if she would conduct the F2F evaluation for patient #1 she stated in part, "I would not have done the F2F because I wasn't aware of what happened. The nurse that had the call would complete it."