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Based on document review, medical record review and interview it was revealed the governing body failed to be responsible for the day to day running of the hospital by ensuring all policies were followed and overseeing the medical staff. The governing body failed to ensure the chief medical officer followed hospital policy for a patient in the emergency room (ER), failed to ensure the on-call physician for an emergency patient appeared to see the patient after notification, failed to ensure a patient presenting to the ER was permitted to be treated by the ER staff and failed to ensure medical staff followed the credentialing code of conduct. These failures have the potential to affect all patients in the hospital. (See tag 0049)

A. Based on document review, medical record review and interview it was revealed the governing body failed to be responsible for the day to day running of the hospital by ensuring the policy for informed consent was followed by the chief medical officer for one (1) of ten (10) patients (patient #1) in the ER. This failure has the potential to affect all patients in the hospital.

Findings include:

1. A review of the document entitled 'Corporate Bylaws of Appalachian Regional Healthcare, Inc.' revealed in part: "The ARH (Appalachian Regional Hospital) Committee on Care and Quality ...Policy and Practice. The committee shall conduct itself as a for the discussion of matters of health care policy and practice, especially those pertaining to efficient and effective patient care ...Quality Improvement. The committee shall conduct itself as a forum for the discussion of matters of quality improvement, quality assurance, process improvement ...The committee shall be responsible for the development and review of methods for the protection and care of hospital patients ..."

2. A review of the document entitled 'Beckley ARH Medical Staff Bylaws,' revised 2/18, revealed in part: "Subject to approval by the Governing Body, the Medical Staff has adopted the following Bylaws that are intended to govern the organization, operation, and self-discipline of the Medical Staff an such Appendix I as may be necessary to implement that general principles found within such Bylaws, to promote the delivery of quality healthcare within the Hospital and to provide for the efficient operation of the Hospital. Each appointee to the Medical Staff shall exercise his or her clinical privileges within the Hospital subject to the provisions contained within such Bylaws and Appendix I and further subject to the policies, procedures and directives of the Governing Body and any restrictions or limitations attached to his or her appointment ..."

3. A review of the document entitled 'Beckley ARH Hospital Appendix I,' revised 8/19, revealed in part: "In addition to obtaining the patient's general consent to treatment, informed consent shall be obtained from the patient or his representative for special treatment ..."

4. A review of the document entitled 'Sexual Assault Forensic - Medical Exam: SAFE,' last reviewed 2/17, revealed in part: "Informed consent will be obtained prior to the examination being conducted ...Hospital personnel will collect samples only with the consent of the patient or in response to a court-ordered search warrant ..."

5. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 11:30 a.m. by a registered nurse: "Attempted to perform Sexual Assault Assessment and obtain history of substance abuse. Pt (patient) unable to respond verbally ..."

6. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 1:40 p.m. by the ER physician: "Patient altered. Patient slumped over in bed with his/her head between the bed railing. Beckley Police Department at bedside. Administration notified that patient could not consent to a rape kit at this point due to being altered."

7. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 1:57 p.m. by the ER physician: "Called by Dr.___, Regional CMO, who states she/he wants patient to have a rape kit done as part of the MSE (medical screening examination). She/he stated that she/he had spoken with Dr. ___ CMO, and Dr. ___, RMO SCP Health and that I would be terminated if I do not perform a rape kit. She/he further stated to me that "my head was on the chopping block." I stated MSE had already been performed and that patient is altered so therefore he/she cannot consent to a rape kit ..."

8. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 3:45 p.m. by the ER physician: "Patient re-evaluated and is alert and oriented. The patient refused a rape kit and further physical examination ..."

9. An interview conducted with RN #1 on 9/28/21 at approximately 9:15 a.m. revealed he/she was an educator and had shared an office with the ER physician. He/she stated the patient has to give consent for a rape kit. He/she stated he/she heard the conversation between the ER physician and the CMO. He/she stated the CMO had called the ER physician concerning the rape kit being done. He/she stated the CMO said the ER physician would need to do the rape kit or she/he would be terminated. The ER physician had told the CMO the patient was altered and could not give consent. The CMO had said she/he should do the rape kit as part of the MSE. The ER physician told the CMO to come to the ER and evaluate the patient.

10. An interview conducted with the Director of Quality on 9/28/21 at approximately 1:30 p.m. revealed they could not do a rape kit if the patient cannot consent to have it done. He/she stated he/she checked with the patient later in the day when he/she was alert to see if he/she would consent to the rape kit and the patient refused.

11. An interview was conducted with the ICEO on 9/28/21 at approximately 2:20 p.m. and he/she agreed to the above findings.


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B. Based on document review and staff interview it was revealed the governing body failed to ensure medical staff upheld their own policies and regulations in two (2) out of ten (10) medical records reviewed (patient #3 and 5). This failure has the potential to negatively impact any patient receiving the services of this facility.

Findings include:

1. Patient #3 presented to the emergency department (ED) on 6/27/21 with a foreign body in the left ear and complaints of a pain level of ten (10) out of ten (10). The on-call ENT (ear, nose, and throat) physician was asked to come to the ED to evaluate the patient and refused. The ED physician ultimately performed moderate sedation on the patient to retrieve the foreign body and relieve the patient's pain.

2. A review of the ED schedule for 6/27/21 revealed there was only one (1) scheduled physician to attend a twenty-six (26) bed ED.

3. A review of the hospital's on-call schedule for 6/27/21 revealed the Chief Medical Officer (CMO) (ENT physician) was on-call.

4. A review of the hospital document entitled 'ED Notes' dated 6/27/21 at 12:47 p.m. states, "I contacted (physician #1) via phone and I requested her/him to see pt. (patient) in ER (emergency room). She/he states, "Bead removal isn't done in the ER on Sunday. She/he can come to my office in the morning." I informed her/him the patient was in extreme pain and would not be able to wait until the morning. (Physician #1) states, "(Physician #2) is welcome to admit the patient to the pediatrician and I can see her/him after she/he is on the floor."

5. A review of the hospital document entitled 'Emergency Department Note' dated 6/27/21 at 3:30 p.m. states: "Nursing spoke with (physician #1) as it was requested, she/he come to see patient in ER. Nursing reports (physician #1) did not feel patient needed to be seen in the ER and stated patient could be admitted to peds instead. Patient was in significant pain and so mother agreed to have patient sedated in ER and attempt removal understanding risks/benefits."

6. A review of the hospital document entitled 'Beckley ARH Hospital Appendix I,' last revised August 2019, states: "On-call practitioners must respond to a call or page within thirty (30) minutes. Therefore, the on-call practitioner must attend to the needs of the patient within a reasonable time and appropriate to the patient's condition, as determined by the Emergency Room practitioner in consultation with the on-call practitioner."

7. An interview was conducted with house nurse coordinator (HNC) #2 on 9/30/21 at approximately 10:45 a.m. He/she stated, "On-call (CMO) physician did refuse to come in."

8. An interview was conducted with the Interim Chief Executive Officer (ICEO) on 9/27/21 at approximately 3:35 p.m. She/he stated that it was the expectation that the on-call physician should have come in to evaluate the patient at the request of the ED physician.

9. A review of the hospital document entitled 'Emergency Suite Log' dated 7/18/21 revealed patient #5 was not listed on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) on 7/18/21.

10. An interview was conducted with the medical staff coordinator (MSC) on 9/28/21 at approximately 9:40 a.m. When questioned about the allegations involving nurse practitioner #1 and physician #1, she/he stated, "The patient was the NP's mother. She/he refused to let the ED staff see the patient."

11. An interview was conducted with security guard #1 on 9/28/21 at approximately 3:50 p.m. He/she stated, "The NP came in the door cursing and berating the nurses. At that time, I didn't know who she/he was. I let the NP know the patient had to be triaged. The NP said, "Fine, I'll triage him/her myself." The NP grabbed the EMS (Emergency Medical Services) stretcher and demanded patient #5 be placed in an ED bed. The NP was cursing and was upsetting the other patients. I explained that it reflected poorly on the hospital and the NP needed to calm down. Physician #1 came over to me and asked who I was and who I thought I was to talk to her/him. He/she stated, "I am a doctor here. I have rights here." The NP grabbed one of the nurse's computers. I explained that even though she/he worked there she/he didn't get special privileges. The NP through a fit. She/he was cursing at staff, saying she/he was an fucking nurse practitioner there. It was trying to fight fire with fire. She/he was irate. Wasn't going to calm down until he/she got what he/she wanted."

12. An interview was conducted with admissions registration clerk #1 on 9/28/21 at approximately 4:30 p.m. She/he stated, "I heard him/her (NP) talking to the other registration clerk telling him/her she/he would just register the patient herself/himself. I took over registering the patient and the NP pointed his/her finger in my face and said, "You don't know who I am. I've been a nurse practitioner here longer than you have been alive." She/he was just telling us we were beneath her/him and we were a bunch of bitches. She/he was going through our papers in registration that she/he had no business going through. It was other patient's confidential information. Registration clerk #1 stated, "When the NP went out the door, he/she told us at least the people on the second floor are nicer than you bitches down here."

13. An interview was conducted with registered nurse #2 on 9/29/21 at approximately 7:55 a.m. He/she stated, "NP #1 took ambulance stretcher down the hall. He/she got on one of our COWs (computer) trying to put orders in on the patient. He/she got an IV (intravenous) kit and started an IV while patient was in the hallway. He/she just would not calm down. He/she took off with patient down the hallway towards radiology demanding an X-ray be done. They didn't even have an order for it."

14. An interview with house nurse coordinator (HNC) #1 was conducted on 9/29/21 at approximately 8:00 a.m. He/she stated, "When I got to the ED NP #1 was screaming and hollering at admissions. Admission clerk had no idea who she/he was. She/he was demanding that they get the patient registered but was refusing to answer the registration clerk's questions so they could get the patient registered. Physician #1 stated, "Let's take her to X-ray." Got to X-ray there was no order. They came back to the ED and got one of the ED physician's prescriptions and wrote an order for an X-ray. The NP was going through registration's papers looking at other patient's information that had no business being in. It was just awful. Physician #1 said she/he wanted the patient to be put in a bed upstairs. I got him/her a bed and put him/her in it. At that time, I thought that was the best thing to do. The NP had people crying and upset. The ED staff were just trying to do what they were supposed to do. HNC #1 stated the administrator on-call was notified and he/she was instructed to go ahead and place patient in a bed. He/she stated that patient #5 never received a COVID-19 swab prior to going to the second floor.

15. An interview was conducted with the Director of Quality on 9/29/21 at approximately 9:45 a.m. He/she stated, "I was the administrator on call that night. Anytime we have a physician issue, we were to automatically notify the former CEO. He/she stated to go ahead and put the patient in a bed, and she/he would deal with the physician in the morning." He/she concurred that NP #1 should not have been looking at other patient's confidential information."

16. An interview was conducted with HNC #2 on 9/29/21 at approximately 10:45 a.m. He/she stated that it was the expectation if a patient was to be a direct admit to the hospital, the admitting physician would call ahead and ask if a bed was available, if the bed is available the bed would be assigned to the patient. The patient is supposed to be registered downstairs prior to coming upstairs and have a COVID-19 swab and results back prior to the patient coming to the floor.

17. A review of the hospital's investigation into the conduct of NP #1 and physician #1 states, "20:47 (8:47 p.m.) Regional Command called-reported 80 yr. (year) with possible fx (fractured) hip in route to ER by Jan Care 31. Approximately 2100 (9:00 p.m.) Jan Care brought patient on stretcher near bed 16 (sixteen) accompanied by physician #1 and unidentified person. Physician #1 asked nurse to help him/her place patient on bed. Physician #1 informed by ER staff the patient needed to be registered and triaged first. Unidentified person entered admissions area, stated he/she would triage patient herself. Cussing at staff. Unidentified person then entered triage room going through the drawers. Unidentified person never identified himself/herself. Another patient at the registration window; log of admitted patients on the desk. HIPAA (Health Insurance Portability Accountability Act) violation of patient information. EMS crew member stated was told by unidentified person to bypass registration and triage and place patient in a room. HNC never contacted for a bed for a direct admission, no orders for X-rays or direct admission when patient arrived. Cussing by unidentified person and searching through paperwork folder witnessed by ER staff. Unidentified person took IV equipment from ER supply room and started an IV on the patient while in the hallway. Patient taken to radiology by physician #1 and unidentified person accompanied by EMS crew. Patient had not been registered, no armband present, no order in meditech. APRN (Advanced Practice Registered Nurse) (NP # 1) demanding X-ray to be done without patient ID or registration or consent to treat. Radtech stated she/he needed an order first. ER provider gave physician #1 a Rx (prescription) pad then physician #1 wrote an order for X-ray Lt (left) Hip/fx BIL (bilateral). Delay in treatment for patient. 1. No orders written. 2. No registration. 3. No consent to treat. 4. Radiology unable to X-ray until patient registered and order placed. 5. First order for Lt hip CXR (chest X-ray) canceled. Corrected order voiced and entered in Meditech (verbal order to Radtech by physician #1 for right hip X-ray). The patient was then registered as CLI (clinical account) and order entered. After right hip X-ray read by physician #1 (she/he was at patient's bedside), the patient was then registered as a direct patient under physician #1's service. HNC assigned a bed on second floor. Admission clerk was told patient was in the front lobby; patient was already taken to the second floor by this time. Admission clerk went to second floor to have admission papers signed. Patient did not have an armband when the clerk verified the patient. He/she verified the name and DOB (date of birth) then placed the admission armband on the patient. Papers signed by the son/daughter, NP #1. Unidentified person was NP #1 that worked for physician #1. Many complaints R/T (related to) NP #1's language and behavior. Yelling out "F" bomb multiple times, calling the staff bitches, very inappropriate, non-professional, foul language. NP #1, son/daughter of patient, absolutely refused registration and triage, refused to sign consent for permission to bill when admission clerk was attempting to register the patient. NP #1 cussing the clerk, calling him/her stupid, NP #1 stated he/she worked here for thirty (30) plus years and he/she was not stupid. Security notified d/t (due to) male/female aggression and cussing. Security responded to loud voices. They were told by NP #1 he/she was "Fucking putting orders in." He/she was a "Fucking nurse practitioner for thirty (30) years and he/she is not going to hear a God d--- thing from no one or nothing from any Fucking body." Patients, family members, staff all within hearing distance. Physician #1 signed the patient paperwork for HIPAA privacy-witnessed by admission clerk. Patient taken to room 202- no COVID swab collected. POOR/ZERO communication from provider and NP #1 with staff when patient arrived at the facility. No communication with HNC prior to patient presenting to facility, (if patient was to be direct admit or just for OP X-Ray). Failure to explain plan of care for patient with staff. Failure to identify himself/herself to the admission clerks or security staff. Inappropriate, unacceptable, non-professional foul language and aggressive behavior with all staff involved. Failure to follow policy and procedures."

18. A review of the hospital policy entitled 'Code of Conduct,' reviewed 8/2018, states: "To aid in both the education of Medical Staff members and Allied Health Professional and the enforcement of this Policy, examples of "inappropriate conduct" include, but are not limited to: Threatening or abusive language directed at patients, families, nurses, hospital personnel, Allied Health Professionals or other physicians (e.g., belittling, berating, and/or non-constructive criticism that intimidates, undermines confidence, or implies incompetence) degrading or demeaning comments regarding patients, families, nurses, physicians, hospital personnel or the hospital, profanity or similarly offensive language while in the hospital and/or while speaking with nurses or other hospital personnel, inappropriate physician contact with another individual that is threatening or intimidating, derogatory comments about the quality of care being provided by the hospital, another Medical Staff member, and any other individual outside of appropriate Medical Staff and/or administrative channels ..."

19. A review of a document signed by the previous Director of Risk dated 7/22/21 states, "July 21, 2021 I returned CMO call. CMO is chairman of Medical Executive Committee and Chief of staff. CMO requested meeting for physician #1 and NP #1 ..., former CEO and myself for Thursday July 22,2021. Medical staff coordinator was asked to send invites to physician #1 and NP #1. They responded with acceptance. 10:15 a.m., July 22, 2021 the scheduled 5:15 p.m. meeting was canceled by (former) CEO.

20. An interview was conducted with the MSC on 9/28/21. He/she stated, "The CMO was supposed to have taken the issue involving the behavior of physician #1 and NP #1 to the Medical Executive Committee (MEC). The issue was never discussed in MEC."

21. A review of the MEC meeting minutes dated 8/25/21 revealed no discussion was made related to the behavior of physician #1 or NP #1.

22. A review of a letter sent to the former CEO dated July 21, 2021 states, "Effectively immediately the following members of our group will be taking a leave of absence for an undetermined length of time. Physician #1 and NP #1 will begin the leave of absence effective 12:01 A.M., July 23, 2021. All currently admitted patients will be provided continuity of care until their discharge."

23. A review of a letter addressed to the former CEO and CMO dated July 29, 2021 states, "Effective July 30, 2021 at 12:01 p.m.: Physician #1 and NP #1 will return to active medical staff from leave of absence."

24. A review of the hospital policy entitled 'Leave of Absence,' approved 10/9/08 states, "A staff appointee may obtain a voluntary leave of absence by providing written notice to the President of the Medical Staff and the Medical Executive Committee. The notice must state the reasons for the leave and approximate period of time of the leave, which may not exceed six (6) months." The policy further states, "During the leave of absence, the practitioner's clinical privileges and responsibilities are suspended."

25. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/23/21 at 12:47 p.m. revealed it was signed by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

26. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/24/21 at 12:56 p.m. revealed it was signed by physician # 1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

27. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/26/21 at 12:31 p.m. revealed it was documented by physician # 1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

28. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/28/21 at 2:38 p.m. revealed it was documented by physician # 1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

29. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/29/21 at 5:54 p.m. revealed it was documented by physician # 1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

30. An interview was conducted with the ICEO on 9/28/21 at approximately 2:30 p.m. He/she concurred that if a physician/NP was on a leave of absence, they should not be seeing patients in the hospital.

Based on staff interview it was determined the hospital failed to ensure patient information was kept private and safe in the Emergency Department (ED). This failure has the potential to compromise the privacy and safety of any patient requesting services in the ED.

Findings include:

1. An interview was conducted with admissions registration clerk #1 on 9/28/21 at approximately 4:30 p.m. She/he stated, "I heard him/her (nurse practitioner) (NP) talking to the other registration clerk telling him/her she/he would just register the patient herself/himself. I took over registering the patient and the NP pointed his/her finger in my face and said "You don't know who I am. I've been a NP here longer than you have been alive." She/he was just telling us we were beneath her/him and we were a bunch of bitches." She/he was going through our papers in registration that she/he had no business going through. It was other patient's confidential information. Registration clerk #1 stated, "When the NP went out the door, he/she told us at least the people on the second floor are nicer than you bitches down here."

2. An interview with house nurse coordinator (HNC) #1 was conducted on 9/29/21 at approximately 8:00 a.m. He/she stated, "When I got to the ED NP #1 was screaming and hollering at admissions. Admission clerk had no idea who she/he was. She/he was demanding that they get the patient registered but was refusing to answer the registration clerk's questions so they could get the patient registered. Physician #1 stated, "Let's take him/her to X-ray." Got to X-ray there was no order. They came back to the ED and got one of the ED physician's prescriptions and wrote an order for an X-ray. The NP was going through registration's papers looking at other patient's information that had no business being in. It was just awful. Physician #1 said he wanted the patient to be put in a bed upstairs. I got him/her a bed and put him/her in it. At that time, I thought that was the best thing to do. The NP had people crying and upset. The ED staff were just trying to do what they were supposed to do. HNC #1 stated the administrator on-call was notified and he/she was instructed to go ahead and place patient in a bed. He/she stated that patient #5 never received a COVID-19 swab prior to going to the second floor.

3. A review of the hospital's investigation into the conduct of NP #1 and physician #1 states, "20:47 (8:47 p.m.) Regional Command called-reported 80 yr. (year) with possible fx (fractured) hip in route to ER by Jan Care 31. Approximately 2100 (9:00 p.m.) Jan Care brought patient on stretcher near bed 16 (sixteen) accompanied by physician #1 and unidentified person. Physician #1 asked nurse to help him/her place patient on bed. Physician #1 informed by ER staff the patient needed to be registered and triaged first. Unidentified person entered admissions area, stated he/she would triage patient herself. Cussing at staff. Unidentified person then entered triage room going through the drawers. Unidentified person never identified himself/herself. Another patient at the registration window; log of admitted patients on the desk. HIPAA (Health Insurance Portability Accountability Act) violation of patient information. EMS crew member stated was told by unidentified person to bypass registration and triage and place patient in a room. HNC never contacted for a bed for a direct admission, no orders for X-rays or direct admission when patient arrived. Cussing by unidentified person and searching through paperwork folder witnessed by ER staff. Unidentified person took IV equipment from ER supply room and started an IV on the patient while in the hallway. Patient taken to radiology by physician #1 and unidentified person accompanied by EMS crew. Patient had not been registered, no armband present, no order in meditech. APRN (Advanced Practice Registered Nurse) (NP # 1) demanding X-ray to be done without patient ID or registration or consent to treat. Radtech stated she/he needed an order first. ER provider gave physician #1 a Rx (prescription) pad then physician #1 wrote an order for X-ray Lt (left) Hip/fx BIL (bilateral). Delay in treatment for patient. 1. No orders written. 2. No registration. 3. No consent to treat. 4. Radiology unable to X-ray until patient registered and order placed. 5. First order for Lt hip CXR (chest X-ray) canceled. Corrected order voiced and entered in Meditech (verbal order to Radtech by physician #1 for right hip X-ray). The patient was then registered as CLI (clinical account) and order entered. After right hip X-ray read by physician #1 (she/he was at patient's bedside), the patient was then registered as a direct patient under physician #1's service. HNC assigned a bed on second floor. Admission clerk was told patient was in the front lobby; patient was already taken to the second floor by this time. Admission clerk went to second floor to have admission papers signed. Patient did not have an armband when the clerk verified the patient. He/she verified the name and DOB (date of birth) then placed the admission armband on the patient. Papers signed by the son/daughter, NP #1. Unidentified person was NP #1 that worked for physician #1. Many complaints R/T (related to) NP #1's language and behavior. Yelling out "F" bomb multiple times, calling the staff Bitc-s, very inappropriate, non-professional, foul language. NP #1, son/daughter of patient, absolutely refused registration and triage, refused to sign consent for permission to bill when admission clerk was attempting to register the patient. NP #1 cussing the clerk, calling him/her stupid, NP #1 stated he/she worked here for thirty (30) plus years and he/she was not stupid. Security notified d/t (due to) male/female aggression and cussing. Security responded to loud voices. They were told by NP #1 he/she was "Fucking putting orders in." He/she was a Fucking nurse practitioner for thirty (30) years, and he/she is not going to hear a God d--- thing from no one or nothing from any Fucking body." Patients, family members, staff all within hearing distance. Physician #1 signed the patient paperwork for HIPAA privacy-witnessed by admission clerk. Patient taken to room 202- no COVID swab collected. POOR/ZERO communication from provider and NP #1 with staff when patient arrived at the facility. No communication with HNC prior to patient presenting to facility, (if patient was to be direct admit or just for OP X-Ray). Failure to explain plan of care for patient with staff. Failure to identify himself/herself to the admission clerks or security staff. Inappropriate, unacceptable, non-professional foul language and aggressive behavior with all staff involved. Failure to follow policy and procedures."

4. An interview was conducted with the Director of Quality on 9/29/21 at approximately 9:45 a.m. He/she stated, "I was the administrator on call that night. Anytime we have a physician issue, we were to automatically notify the former CEO. He/she stated to go ahead and put the patient in a bed, and she/he would deal with the physician in the morning." He/she concurred that NP #1 should not have been looking at other patient's confidential information.

Based on document review and staff interview it was revealed the hospital failed to ensure all patients receiving the services of the Emergency Department (ED) was provided personal privacy on the evening of 7/18/21. This failure has the potential to negatively impact the patients receiving the services of the ED.

Findings include:

1. An interview was conducted with admissions registration clerk #1 on 9/28/21 at approximately 4:30 p.m. She/he stated, "I heard him/her (nurse practitioner) (NP) talking to the other registration clerk telling him/her she/he would just register the patient herself/himself. I took over registering the patient and the NP pointed his/her finger in my face and said "You don't know who I am. I've been a NP here longer than you have been alive." She/he was just telling us we were beneath her/him and we were a bunch of bitches." She/he was going through our papers in registration that she/he had no business going through. It was other patient's confidential information. Registration clerk #1 stated, "When the NP went out the door, he/she told us at least the people on the second floor are nicer than you bitches down here."

2. An interview with house nurse coordinator (HNC) #1 was conducted on 9/29/21 at approximately 8:00 a.m. He/she stated, "When I got to the ED NP #1 was screaming and hollering at admissions. Admission clerk had no idea who she/he was. She/he was demanding that they get the patient registered but was refusing to answer the registration clerk's questions so they could get the patient registered. Physician #1 stated, "Let's take him/her to X-ray." Got to X-ray there was no order. They came back to the ED and got one of the ED physician's prescriptions and wrote an order for an X-ray. The NP was going through registration's papers looking at other patient's information that had no business being in. It was just awful. Physician #1 said he wanted the patient to be put in a bed upstairs. I got him/her a bed and put him/her in it. At that time, I thought that was the best thing to do. The NP had people crying and upset. The ED staff were just trying to do what they were supposed to do. HNC #1 stated the administrator on-call was notified and he/she was instructed to go ahead and place patient in a bed. He/she stated that patient #5 never received a COVID-19 swab prior to going to the second floor.

3. A review of the hospital's investigation into the conduct of NP #1 and physician #1 states, "20:47 (8:47 p.m.) Regional Command called-reported 80 yr. (year) with possible fx (fractured) hip in route to ER by Jan Care 31. Approximately 2100 (9:00 p.m.) Jan Care brought patient on stretcher near bed 16 (sixteen) accompanied by physician #1 and unidentified person. Physician #1 asked nurse to help him/her place patient on bed. Physician #1 informed by ER staff the patient needed to be registered and triaged first. Unidentified person entered admissions area, stated he/she would triage patient herself. Cussing at staff. Unidentified person then entered triage room going through the drawers. Unidentified person never identified himself/herself. Another patient at the registration window; log of admitted patients on the desk. HIPAA (Health Insurance Portability Accountability Act) violation of patient information. EMS crew member stated was told by unidentified person to bypass registration and triage and place patient in a room. HNC never contacted for a bed for a direct admission, no orders for X-rays or direct admission when patient arrived. Cussing by unidentified person and searching through paperwork folder witnessed by ER staff. Unidentified person took IV equipment from ER supply room and started an IV on the patient while in the hallway. Patient taken to radiology by physician #1 and unidentified person accompanied by EMS crew. Patient had not been registered, no armband present, no order in meditech. APRN (Advanced Practice Registered Nurse) (NP # 1) demanding X-ray to be done without patient ID or registration or consent to treat. Radtech stated she/he needed an order first. ER provider gave physician #1 a Rx (prescription) pad then physician #1 wrote an order for X-ray Lt (left) Hip/fx BIL (bilateral). Delay in treatment for patient. 1. No orders written. 2. No registration. 3. No consent to treat. 4. Radiology unable to X-ray until patient registered and order placed. 5. First order for Lt hip CXR (chest X-ray) canceled. Corrected order voiced and entered in Meditech (verbal order to Radtech by physician #1 for right hip X-ray). The patient was then registered as CLI (clinical account) and order entered. After right hip X-ray read by physician #1 (she/he was at patient's bedside), the patient was then registered as a direct patient under physician #1's service. HNC assigned a bed on second floor. Admission clerk was told patient was in the front lobby; patient was already taken to the second floor by this time. Admission clerk went to second floor to have admission papers signed. Patient did not have an armband when the clerk verified the patient. He/she verified the name and DOB (date of birth) then placed the admission armband on the patient. Papers signed by the son/daughter, NP #1. Unidentified person was NP #1 that worked for physician #1. Many complaints R/T (related to) NP #1's language and behavior. Yelling out "F" bomb multiple times, calling the staff Bitchs, very inappropriate, non-professional, foul language. NP #1, son/daughter of patient, absolutely refused registration and triage, refused to sign consent for permission to bill when admission clerk was attempting to register the patient. NP #1 cussing the clerk, calling him/her stupid, NP #1 stated he/she worked here for thirty (30) plus years and he/she was not stupid. Security notified d/t (due to) male/female aggression and cussing. Security responded to loud voices. They were told by NP #1 he/she was "Fucking putting orders in." He/she was a Fucking nurse practitioner for thirty (30) years, and he/she is not going to hear a God damn thing from no one or nothing from any Fucking body." Patients, family members, staff all within hearing distance. Physician #1 signed the patient paperwork for HIPAA privacy-witnessed by admission clerk. Patient taken to room 202- no COVID swab collected. POOR/ZERO communication from provider and NP #1 with staff when patient arrived at the facility. No communication with HNC prior to patient presenting to facility, (if patient was to be direct admit or just for OP X-Ray). Failure to explain plan of care for patient with staff. Failure to identify himself/herself to the admission clerks or security staff. Inappropriate, unacceptable, non-professional foul language and aggressive behavior with all staff involved. Failure to follow policy and procedures."

4. An interview was conducted with the Director of Quality on 9/29/21 at approximately 9:45 a.m. He/she stated, "I was the administrator on call that night. Anytime we have a physician issue, we were to automatically notify the former CEO. He/she stated to go ahead and put the patient in a bed, and she/he would deal with the physician in the morning." He/she concurred that NP #1 should not have been looking at other patient's confidential information.

Based on document review, medical record review and interview it was revealed the hospital's Quality Assurance/Performance Improvement (QA/PI) program failed to track, trend and analyze rape kits done in the Emergency Room (ER) and failed to track, trend and analyze that physicians, nurse practitioners (NPs) and physician assistants (PAs) follow their medical staff by-laws and rules and regulations.

Findings include:

1. A review of the document entitled 'Beckley ARH Hospital Appendix I,' revised 8/19, revealed in part: "In addition to obtaining the patient's general consent to treatment informed consent shall be obtained from the patient or his/her representative for special treatment ..."

2. A review of the document entitled 'Sexual Assault Forensic - Medical Exam: SAFE,' last reviewed 2/17, revealed in part: "Informed consent will be obtained prior to the examination being conducted ...Hospital personnel will collect samples only with the consent of the patient or in response to a court-ordered search warrant ..."

3. A review of the QA/PI meeting minutes and agenda revealed there was no data collection or analysis done of rape kits in the ER or that the physicians, NPs or PAs follow their by-laws and rules and regulations.

4. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 1:57 p.m. by the ER physician: "Called by Dr.___, Regional CMO, who states she/he wants patient to have a rape kit done as part of the MSE (medical screening examination) ...I stated MSE had already been performed and that patient is altered so therefore she/he cannot consent to a rape kit ..."

5. An interview conducted with the Director of Quality on 9/28/21 at approximately 1:30 p.m. revealed they could not do a rape kit if the patient cannot consent to have it done. He/she stated he/she checked with the patient later in the day when he/she was alert to see if he/she would consent to the rape kit and the patient refused.

6. An interview with the Director of Quality on 9/28/21 at approximately 1:30 p.m. revealed they do not track rape kits in the ER or if the physicians, NPs and PAs follow their bylaws and rules and regulations unless there is an adverse event.

7. An interview was conducted with the Director of Quality on 9/29/21 at approximately 9:45 a.m. and he/she agreed with the above findings.

Based on document review, medical record review and interview it was revealed the medical staff failed to follow their bylaws and rules and regulations by demanding staff disregard hospital policies and procedures, failed to see a patient while on call for the emergency department (ED) and failed to follow policy and procedure for the admission and treatment of a patient presenting to the ED by Emergency Medical Services (EMS). The medical staff also failed to ensure information pertinent for peer review was discussed in their medical executive meetings. (See tag 353 and 363)

A. Based on document review, medical record review and interview it was revealed the medical staff failed to follow their bylaws and rules and regulations by demanding emergency room (ER) staff perform a rape kit on an incapacitated patient in one (1) of ten (10) patients (patient #1) which is in violation of the hospital policy and procedure for performing rape kits. This failure has the potential to affect all incapacitated patients presenting to the ER for care.

Findings include:

1. A review of the document entitled 'Beckley ARH Medical Staff Bylaws,' revised 2/18, revealed in part: "Subject to approval by the Governing Body, the Medical Staff has adopted the following Bylaws that are intended to govern the organization, operation, and self-discipline of the Medical Staff an such Appendix I as may be necessary to implement that general principles found within such Bylaws, to promote the delivery of quality healthcare within the Hospital and to provide for the efficient operation of the Hospital. Each appointee to the Medical Staff shall exercise his or her clinical privileges within the Hospital subject to the provisions contained within such Bylaws and Appendix I and further subject to the policies, procedures and directives of the Governing Body and any restrictions or limitations attached to his or her appointment ..."

2. A review of the document entitled 'Beckley ARH Hospital Appendix I,' revised 8/19, revealed in part: "In addition to obtaining the patient's general consent to treatment Informed consent shall be obtained from the patient or his representative for special treatment ..."

3. A review of the document entitled 'Sexual Assault Forensic - Medical Exam: SAFE,' last reviewed 2/17, revealed in part: "Informed consent will be obtained prior to the examination being conducted ...Hospital personnel will collect samples only with the consent of the patient or in response to a court-ordered search warrant ..."

4. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 11:30 a.m. by a registered nurse: "Attempted to perform Sexual Assault Assessment and obtain history of substance abuse. Pt unable to respond verbally ..."

5. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 1:40 p.m. by the ER physician: "Patient altered. Patient slumped over in bed with his/her head between the bed railing. Beckley Police Department at bedside. Administration notified that patient could not consent to a rape kit at this point doe to being altered."

6. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 1:57 p.m. by the ER physician: "Called by Dr.___, Regional CMO, who states she/he wants patient to have a rape kit done as part of the MSE. She/he stated that she/he had spoken with Dr. ___ CMO, and Dr. ___, RMO SCP Health and that I would be terminated if I do not perform a rape kit. She/he further stated to me that "my head was on the chopping block". I stated MSE had already been performed and that patient is altered so therefore he/she cannot consent to a rape kit ..."

7. A review of patient #1's medical record revealed the following documentation on 8/31/21 at 3:45 p.m. by the ER physician: "Patient re-evaluated and is alert and oriented. The patient refused a rape kit and further physical examination ...Patient offered medications for urinary tract infection as well as possible STD. Patient did want Plan B for pregnancy prevention."

8. An interview conducted with registered nurse (RN) #1 on 9/28/21 at approximately 9:15 a.m. revealed he/she was an educator and had shared an office with the ER physician. He/she stated the patient has to give consent for a rape kit. He/she stated he/she heard the conversation between the ER physician and the Chief Medical Officer (CMO). He/she stated the CMO had called the ER physician concerning the rape kit being done. He/she stated the CMO said the ER physician would need to do the rape kit or she/he would be terminated. The ER physician had told the CMO the patient was altered and could not give consent. The CMO had said she/he should do the rape kit as part of the Medical Screening Examination (MSE). The ER physician told the CMO to come to the ER and evaluate the patient. He/she said the CMO said the ER physician's "head was on the chopping block.". He/she also stated the ER physician "was fired within two (2) days of the conversation."

9. An interview conducted with the Director of Quality on 9/28/21 at approximately 1:30 p.m. revealed they could not do a rape kit if the patient cannot consent to have it done. He/she stated he/she checked with the patient later in the day when he/she was alert to see if he/she would consent to the rape kit and the patient refused.

10. An interview was conducted with the Interim CEO on 9/28/21 at approximately 2:20 p.m. and he/she agreed with the above findings.


38717

B. Based on document review and staff interview it was revealed the hospital failed to ensure the hospitals by laws were enforced in two (2) out of the ten (20) medical records reviewed (patient #3 and 5). This failure puts all patients receiving the services of the hospital's physicians at risk of receiving inappropriate care that could risk the health of the patients seeking their services.

Findings include:

1. Patient #3 presented to the Emergency Department (ED) on 6/27/21 with a foreign body in the left ear and complaints of a pain level of ten (10) out of ten (10). The on-call ENT (ear, nose, and throat) physician was asked to come to the ED to evaluate the patient and refused. The ED physician ultimately performed moderate sedation on the patient to retrieve the foreign body and relieve the patient's pain.

2. A review of the ED schedule for 6/27/21 revealed there was only one (1) scheduled physician to attend a twenty-six (26) bed ED.

3. A review of the hospital's on-call schedule for 6/27/21 revealed the CMO (ENT physician) was on-call.

4. A review of the hospital document entitled 'ED Notes' dated 6/27/21 at 12:47 p.m. states, "I contacted (physician #1) via phone and I requested her/him to see pt. (patient) in ER (emergency room). She/he states, "Bead removal isn't done in the ER on Sunday. She/he can come to my office in the morning." I informed her/him the patient was in extreme pain and would not be able to wait until the morning. (Physician #1) states, "(Physician #2) is welcome to admit the patient to the pediatrician and I can see her/him after she/he is on the floor."

5. A review of the hospital document entitled 'Emergency Department Note' dated 6/27/21 at 3:30 p.m. states: "Nursing spoke with (physician #1) as it was requested, she/he come to see patient in ER. Nursing reports (physician #1) did not feel patient needed to be seen in the ER and stated patient could be admitted to peds instead. Patient was in significant pain and so mother agreed to have patient sedated in ER and attempt removal understanding risks/benefits."

6. A review of the hospital document entitled 'Beckley ARH Hospital Appendix I,' last revised August 2019, states: "On-call practitioners must respond to a call or page within thirty (30) minutes. Therefore, the on-call practitioner must attend to the needs of the patient within a reasonable time and appropriate to the patient's condition, as determined by the Emergency Room practitioner in consultation with the on-call practitioner."

7. An interview was conducted with house nurse coordinator (HNC) #2 on 9/30/21 at approximately 10:45 a.m. He/she stated, "On-call (CMO) physician did refuse to come in."

8. An interview was conducted with the Interim Chief Executive Officer (ICEO) on 9/27/21 at approximately 3:35 p.m. She/he stated that it was the expectation that the on-call physician should have come in to evaluate the patient at the request of the ED physician.

Based on document review and staff interview it was revealed the hospital failed to ensure that physician #1's hospital privileges were suspended while he/she was on a leave of absence. This failure has the potential to negatively impact the patient's receiving the services of this physician.

Findings include:

1. A review of a letter sent to the former Chief Executive Officer (CEO) dated July 21, 2021 states, "Effectively immediately the following members of our group will be taking a leave of absence for an undetermined length of time. Physician #1 and nurse practitioner (NP) #1 will begin the leave of absence effective 12:01 A.M., July 23, 2021. All currently admitted patients will be provided continuity of care until their discharge."

2. A review of a letter addressed to the former CEO and Chief Medical Officer (CMO) dated July 29, 2021 states, "Effective July 30, 2021 at 12:01 p.m.: Physician #1 and NP #1 will return to active medical staff from leave of absence."

3. A review of the hospital policy entitled 'Leave of Absence,' approved 10/9/08 states, "A staff appointee may obtain a voluntary leave of absence by providing written notice to the President of the Medical Staff and the Medical Executive Committee. The notice must state the reasons for the leave and approximate period of time of the leave, which may not exceed six (6) months." The policy further states, "During the leave of absence, the practitioner's clinical privileges and responsibilities are suspended."

4. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/23/21 at 12:47 p.m. revealed it was signed by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

5. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/24/21 at 12:56 p.m. revealed it was signed by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

6. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/26/21 at 12:31 p.m. revealed it was documented by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

7. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/28/21 at 2:38 p.m. revealed it was documented by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

8. A review of the hospital document entitled 'Internal Medicine Progress Note Signed' dated 7/29/21 at 5:54 p.m. revealed it was documented by physician #1, proving the physician was still performing patient care in the hospital after going on a leave of absence.

9. An interview was conducted with the Interim CEO on 9/28/21 at approximately 2:30 p.m. He/she concurred that if a physician and/or NP was on a leave of absence, they should not be seeing patients in the hospital.

Based on document review and staff interview it was revealed the hospital failed to ensure Emergency Department policy and procedure was followed in two (2) out of ten (10) medical records reviewed (see tag 1104).

Based on document review and staff interview it was revealed the hospital failed to ensure their own Emergency Department (ED) policies were followed in two (2) out of ten (10) medical records reviewed (patient #3 and 5). This failure has the potential to delay potentially life-saving treatments to the patients seeking emergency services of the hospital.

Findings include:

1. Patient #3 presented to the ED on 6/27/21 with a foreign body in the left ear and complaints of a pain level of ten (10) out of ten (10). The on-call ENT (ear, nose, and throat) physician was asked to come to the ED to evaluate the patient and refused. The ED physician ultimately performed moderate sedation on the patient to retrieve the foreign body and relieve the patient's pain.

2. A review of the ED schedule for 6/27/21 revealed there was only one (1) scheduled physician to attend a twenty-six (26) bed ED.

3. A review of the hospital's on-call schedule for 6/27/21 revealed the Chief Medical Officer (CMO) (ENT physician) was on-call.

4. A review of the hospital document entitled 'ED Notes' dated 6/27/21 at 12:47 p.m. states, "I contacted (physician #1) via phone and I requested her/him to see pt. (patient) in ER (emergency room). She/he states, "Bead removal isn't done in the ER on Sunday. She/he can come to my office in the morning." I informed her/him the patient was in extreme pain and would not be able to wait until the morning. (Physician #1) states, "(Physician #2) is welcome to admit the patient to the pediatrician and I can see her/him after she/he is on the floor."

5. A review of the hospital document entitled 'Emergency Department Note' dated 6/27/21 at 3:30 p.m. states: "Nursing spoke with (physician #1) as it was requested, she/he come to see patient in ER. Nursing reports (physician #1) did not feel patient needed to be seen in the ER and stated patient could be admitted to peds instead. Patient was in significant pain and so mother agreed to have patient sedated in ER and attempt removal understanding risks/benefits."

6. A review of the hospital document entitled 'Beckley ARH Hospital Appendix I,' last revised August 2019, states: "On-call practitioners must respond to a call or page within thirty (30) minutes. Therefore, the on-call practitioner must attend to the needs of the patient within a reasonable time and appropriate to the patient's condition, as determined by the Emergency Room practitioner in consultation with the on-call practitioner."

7. An interview was conducted with house nurse coordinator (HNC) #2 on 9/30/21 at approximately 10:45 a.m. He/she stated, "On-call (CMO) physician did refuse to come in."

8. An interview was conducted with the Interim Chief Executive Officer (ICEO) on 9/27/21 at approximately 3:35 p.m. She/he stated that it was the expectation that the on-call physician should have come in to evaluate the patient at the request of the ED physician.

9. A review of the hospital document entitled 'Emergency Suite Log' dated 7/18/21 revealed patient #5 was not listed on the hospital's Emergency Medical Treatment and Labor Act (EMTALA) on 7/18/21.

10. An interview was conducted with the medical staff coordinator (MSC) on 9/28/21 at approximately 9:40 a.m. When questioned about the allegations involving nurse practitioner #1 and physician #1, she/he stated, "The patient was the NP's mother. She/he refused to let the ED staff see the patient."

11. An interview was conducted with security guard #1 on 9/28/21 at approximately 3:50 p.m. He/she stated, "The NP came in the door cursing and berating the nurses. At that time, I didn't know who she/he was. I let the NP know the patient had to be triaged. The NP said, "Fine, I'll triage him/her myself." The NP grabbed the EMS (Emergency Medical Services) stretcher and demanded patient #5 be placed in an ED bed. The NP was cursing and was upsetting the other patients. I explained that it reflected poorly on the hospital and the NP needed to calm down. Physician #1 came over to me and asked who I was and who I thought I was to talk to her/him. He/she stated, "I am a doctor here. I have rights here." The NP grabbed one of the nurse's computers. I explained that even though she/he worked there she/he didn't get special privileges. The NP through a fit. She/he was cursing at staff, saying she/he was a fucking nurse practitioner there. It was trying to fight fire with fire. She/he was irate. Wasn't going to calm down until he/she got what he/she wanted."

12. An interview was conducted with admissions registration clerk #1 on 9/28/21 at approximately 4:30 p.m. She/he stated, "I heard him/her (NP) talking to the other registration clerk telling him/her she/he would just register the patient herself/himself. I took over registering the patient and the NP pointed his/her finger in my face and said, "You don't know who I am. I've been a nurse practitioner here longer than you have been alive." She/he was just telling us we were beneath her/him and we were a bunch of bitches. She/he was going through our papers in registration that she/he had no business going through. It was other patient's confidential information. Registration clerk #1 stated, "When the NP went out the door, he/she told us at least the people on the second floor are nicer than you bitches down here."

13. An interview was conducted with registered nurse #2 on 9/29/21 at approximately 7:55 a.m. He/she stated, "NP #1 took ambulance stretcher down the hall. He/she got on one of our COWs (computer) trying to put orders in on the patient. He/she got an IV (intravenous) kit and started an IV while patient was in the hallway. He/she just would not calm down. He/she took off with patient down the hallway towards radiology demanding an X-ray be done. They didn't even have an order for it."

14. An interview with house nurse coordinator (HNC) #1 was conducted on 9/29/21 at approximately 8:00 a.m. He/she stated, "When I got to the ED NP #1 was screaming and hollering at admissions. Admission clerk had no idea who she/he was. She/he was demanding that they get the patient registered but was refusing to answer the registration clerk's questions so they could get the patient registered. Physician #1 stated, "Let's take her to X-ray." Got to X-ray there was no order. They came back to the ED and got one of the ED physician's prescriptions and wrote an order for an X-ray. The NP was going through registration's papers looking at other