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Based on medical record review, staff interviews, observations, and document reviews it was determined the facility failed to ensure patient rights due to not reporting patient abuse (see tag A0144), failing to keep Patient free from abuse or harassment (see tag A0145), in one (1) out of ten (10) Patients, Patient #1. This failure has the potential to negatively impact all Patients receiving care at the facility.

Cross reference:
482.13 (c)(2) Patient Rights: The Patient has the right to receive care in a safe setting and 482.13(c)(3): The Patient has the right to be free from all forms of abuse or harassment.

Based on document reviews, medical record review, video observation and staff interviews, it was determined the facility failed to ensure care in a safe setting by not performing fifteen (15) minute safety checks as ordered for one (1) out of ten (10) Patients, Patient #1. This failure has the potential to negatively impact all Patients receiving care at the facility.


Findings include:

A review of the policy, titled "Behavioral Health Special Precautions," reviewed 05/08/23. The policy states, in part, "... Procedure A) Admission/Transfer 1. Upon arrival to the unit, the Patient's belongings are secured, and the Patient is placed on a minimum, precautions that require 15 [fifteen] minute checks that are recorded on the 15 [fifteen] Minute Location/Safety Rounds Record special precautions form. A higher level may be indicated to meet each individual Patient's needs. ... E) ...All referenced checks are completed on the 15 [fifteen] Minute Location/Safety Rounds Record." The times listed on the 15 [fifteen] Minute Location/Safety Rounds Record are approximations. The checks may be completed plus or minus 3 [three] minutes each quarter hour and documented on the quarter hour line ... F. Requirements of all Patient safety checks: 1. Safety checks are performed to validate a Patient 's location, status awake or sleep, and most importantly, General well-being ...4. When performing safety checks when Patients appear to be sleeping, it is vitally important and required that the staff member move physically close enough to the Patient to validate that the Patient is alive and generally well. The staff member must visually and/or acoustically witness the Patient breathing. ex: see the Patient 's chest rising and falling, must hear the Patient breathing ...7. When Patients are sleeping the 1/4 [quarter] hour safety checks must be completed by an RN (Registered Nurse) at least once every hour ..."

The "ROVER Safety Checks" [facility's documentation system for safety checks] were reviewed from 11/16/23 at 3:01 p.m. through 11/21/23 at 11:39 a.m. The Patient's "Safety Measures, Observed Behavior, and Patient Location" were documented for the Patient approximately every fifteen (15) minutes throughout the Patient's stay.

A video observation was made for Patient #1. During the observation, Emp #12 explained the video feed is motion activated, and although it may miss one (1) or two (2) motions, it should pick up most of them.

On 11/18/23 the Patient was observed entering their room, Room 514, at 12:17 a.m. In the video, facility staff was observed opening the Patient's room door and looking in at 1:05 a.m., 1:30 a.m., 2:17 a.m., 3:30 a.m., 4:08 a.m., 4:48 a.m., and 6:08 a.m.

On 11/18/23, the safety checks were documented between 12:17 a.m. and 6:08 a.m. approximately every fifteen (15) minutes by Emp #17.

On 11/19/23, the Patient was observed entering their room at 12:33 a.m. In the video, facility staff was observed opening the Patient's room door and looking in at 3:00 a.m., then again at 4:15 a.m.

On 11/19/23, the safety checks were documented between 12:33 a.m. and 4:15 a.m. approximately every fifteen (15) minutes by Emp #17.

On 11/19/23, the Patient was observed entering their room at 11:55 p.m. On 11/20/23, facility staff opened the Patient 's room door and looked in at 12:19 a.m., 1:01 a.m., 2:30 a.m. and 5:47 a.m.

On 11/20/23, the safety checks were documented between 12:19 a.m. and 5:47 a.m. approximately every fifteen (15) minutes by Emp #7.

On 11/21/23 the Patient was observed entering their room at 12:07 a.m. The facility staff was observed opening the Patient's room door and looking in at 12:26 a.m. No additional checks were observed in the video while the Patient remained in their room, until 6:22 a.m.

On 11/21/23, the safety checks were documented between 12:07 a.m. and 6:22 a.m. approximately every fifteen (15) minutes by Emp #7.

An interview was conducted for Emp #1 on 12/04/23 at 1:47 p.m. Regarding the allegation of abuse of Patient #1 by Emp #4, Emp #1 states in part, "... [Patient #1] was under fifteen (15) minutes standard safety checks ..."

A telephone interview was conducted with Emp #5 on 12/04/23 at 4:19 p.m. Regarding fifteen (15) minute safety checks, Emp #5 states, "We open the door, we look to see if they're sleeping. If we can hear them snoring, we don't open the door, especially room 514 the door is super squeaky. For documenting the checks, usually it depends on who I'm working with. You can document in the iPad or sometimes if someone else would prefer to do that- that staff member does all the iPad documentation, and the other person does the notes and group."

A telephone interview was conducted with Emp #7 on 12/04/23 at 9:04 p.m. Regarding fifteen (15) minute safety checks, Emp #7 states, "We check every Patient every fifteen (15) minutes. If they are in their room, we have to open the door and visualize them. We actually have to lay eyes on them."

An interview was conducted with Emp #9 on 12/05/23 at 8:38 a.m. Regarding fifteen (15) minute safety checks, Emp #9 states, "Every fifteen (15) minutes you're required to have eyes on every Patient. I physically have to see them. For the fifteen (15) minute checks we have to document if they're safe, what they are doing and their location."

Based on document reviews, medical record reviews, video observation and staff interviews, it was determined the facility failed to ensure all Patients were free from abuse or harassment by not ensuring an employee was removed from direct patient care until an investigation was completed after an allegation of sexual abuse reported to the facility by one (1) Patient upon admission, Patient #1 and inappropriate physical restraint in one (1) out of twenty (20) Patients, Patient #11. This failure has the potential to negatively impact all Patients receiving care at the facility.


Findings include:

A policy was reviewed titled, "Adult Abuse Neglect", reviewed November 6, 2023. The policy has a section titled "Purpose" which states, in part, "To establish steps for reporting suspected adult abuse and / or neglect." A section titled "Policy or Procedure" states, in part, "1. Any case of suspected adult abuse or neglect is generally received by Social Services from the Emergency Room physician, attending physician or staff nurse. 2. Social Services will review medical record, if one is available, to obtain pertinent information. 3. Social Services will then contact WV Department of Health and Human Resources Adult Protective Service Unit, who is designated agency to investigate alleged or suspected adult abuse or neglect. 5. Should a Patient allege to Social Services that an act of abuse or neglect occurred at the hand of a hospital employee, nursing supervisor should be immediately notified to begin investigation into the allegations."

A review of the policy, titled "Corrective Action and Discharge," reviewed 03/08/23. The policy states in pertinent part, "... Procedure ... E. Suspension- A suspension may take place at any time during the corrective action process. A supervisor who suspends an employee must contact Human Resources before or immediately following the suspension. An employee may be placed on suspension when he/she commits a serious act, but not so severe as to warrant immediate termination. Employees may be suspended pending the outcome of an investigation if circumstances warrant. Discretion should be used in applying suspension as a management tool ..."

A review of the document, "Event Summary with All Tasks," initiated on 11/28/23 at 3:55 p.m. The event summary included the information obtained from Patient #1's group home, as they called in to report the accusation of sexual abuse against Emp #4 on 11/28/23. The investigation had started and was still in the fact-finding phase. A letter was sent to the complainant, the worker at the group home, on 12/04/23.

Staffing assignments were reviewed from 11/26/23 through 12/2/23 for the Behavioral Health Unit. Emp #4 worked 7:00 p.m. through 7:00 a.m. on 11/28/23 and 11/29/23.

An interview was conducted for Emp #1 on 12/04/23 at 1:47 p.m. Regarding the allegation of abuse of Patient #1 by Emp #4, Emp #1 states, "I talked with staff working with [Emp #4] and they did not see [Emp #4] alone with [Patient #1]. [Emp #4] said [Emp #4] was never alone with [Patient #1]. I did not check on the other [gender] staff. Staff was not to be alone with [Patient #1] due to the fact [Patient #1] had made an allegation previously that staff had physically abused [Patient #1] at [group home]. This Patient was a never a one-to-one (1:1) observation [Patient #1] was under fifteen (15) minutes standard safety checks. We received the allegation of abuse after the Patient had been discharged."

An interview was conducted with Emp #12 on 12/05/23 at 1:41 p.m. Regarding accusations against staff members by Patients, Emp #12 states, "A supervisor can suspend the staff immediately, and then notify Human Resources (HR). They can always notify HR first if they have any questions about what to do involving a certain situation. We would then direct the documentation and make sure what needs to be done is done. We would make sure HR stays engaged in the whole process. There was no notification of this accusation against the staff member to HR as of today."

Proper policy and procedure for physical restraint.

Findings include:

A policy was reviewed titled, "Violent Restraint", reviewed 5/7/23. The policy has a section titled "Purpose" which states, in part, "To provide guidelines for the use of restraint or seclusion in a least restrictive environment which protects Patient's safety, dignity, rights, and physical well-being." A section titled "Policy" states, in part, "The use of restraints or seclusion for behavioral management is limited to those situations where it is necessary to ensure the immediate physical safety of a Patient, staff members, or others. Restraints and seclusion will only be used in emergent situations in which the Patient's behavior threatens the physical safety of the Patient, staff, or others. Restraints and seclusion: Should only be used when all other less restrictive measures have failed. Will be applied safely by staff trained in appropriate restraining techniques. Definitions: Restraint: Any method physical or mechanical that immobilizes or reduces the ability of a Patient to move his/her limbs, body, or head freely. Violent Restraint/Self-destructive Restraint: The use of restraint for a demonstrated outburst of physically aggressive behavior that poses an immediate danger to the Patient or others. Licensed Independent practitioner (LIP) evaluation: A physician or other LIP must see and evaluate the need for restraint or seclusion within one (1) hour after the initiation of restraints.

A policy was reviewed titled, "Use of Restraint Policy", reviewed 6/12/23. The policy has a section titled "Purpose" which states, in part, "Restraints will be used only in clinically appropriate and adequately justified situations. A restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a Patient to move his or her arms, legs, body, or head freely. Restraints are never to be used in a manner which might inadvertently be perceived as a punishment, for the convenience of staff members, or in response to behaviors or circumstances that do not constitute danger of injury to patients, self, or others (i.e., verbal abusive behavior). The decision to use a restraint is not driven by diagnosis, but by a comprehensive individual Patient assessment. A restraint(s) should not be used unless the use of the restraint is necessary to ensure the immediate physical safety of the Patient, a staff member, or others. The use of restraint must be discontinued as soon as possible based on an individualized Patient's assessment and re-evaluation."

A medical record review was conducted for Patient #11. An entry in the medical record on 12/11/23 at 8:49a.m. by EMP #2 indicated that Patient #11 was agitated while getting vital signs checked by EMP #2. Patient was cursing at the staff and stormed to the assigned room". EMP #2 entered Patient #11 ' s room to ' assess the situation ' and a negative interaction occurred. Around 8:30 a.m. Patient #11 is reported to have approached the nursing station and began cursing at EMP #2, EMP #19 and EMP #21. Patient #11 was then restrained by EMP #2 and eventually returned to Patient #11's assigned room.

It should be noted that medical record information does not correlate with interviews or video reviews.


A review of the facilities video of the incident was conducted on 12/14/23 and reveals the following:

7:51 a.m. Emp #21 appears to be taking the vital signs with a machine of Patient #11. Patient #11 sitting in a chair with a camouflage sweatshirt on, with hood up over the head.

7:52:41 a.m. Patient #11 unwraps blood pressure cuff from Patient #11's arm, folds in up and places it in the basket of the vital sign machine.

7:52:55 a.m. Patient #11 stands up and walks to their room, room 512.

7:54:18 a.m. Emp #2 walks into Patient #11's room and shuts the door.

7:54:40 a.m. Emp #21 opens Patient #11's door, enters the room, and shuts the door.

7:55:08 a.m. Emp #21 and Emp #2 exit Patient #11's room, shutting the door.

8:22:09 a.m. Patient #11 exits their room and walks towards the nurse ' s station.

8:22:16 a.m. Patient #11 at the nurse ' s station, with a notebook in their hand. Appears to be talking with staff. Emp #21, Emp #2 and Emp #11 are at the Nurse's station.

8:22:57 a.m. Emp #2 stands up and is talking to Patient #11. Emp #2 appears to be yelling towards the Patient in the video, but no audio is available. Emp #21 walks around nurses ' station and is standing next to Patient #11.

8:22:59 a.m. Emp #21 physically holds the Patient by placing Emp #21's right arm around Patient #11's neck. Emp #2 holds onto Patient #11 left arm.

8:23:38 a.m. Emp #2 is using their knee and pushing the back of Patient #11's calves. Emp #2 appears to be pulling back on Patient #11. Emp #21 still has their arm secured around Patient #11's neck, and Patient #11's head is pulled back. Patient #11 is holding onto the nurses ' station with both hands.

8:24 a.m. Emp #19 removes notebook from Patient #11's hands. Emp #11 is at the nurses' station appearing to be on the telephone.

8:24:05 a.m. Emp #19 is holding Patient #11 left arm, Emp #2 is holding Patient #11's arm and waist, and Emp #21 has their arm still around Patient #11's neck.

8:25:12 a.m. Emp #27 arrives on the unit.

8:25:39 a.m. All three (3) staff members release the Patient.

8:25:40 a.m. Patient #11 walking towards the unit door with Emp #27. Emp #27 has their arms out on both sides of the Patient, but not holding. Patient #11 sits on the floor in front of the unit exit door.

8:26 a.m. Emp #19 reaches their hand towards Patient #11, appearing to offer help getting up.

8:26:38 a.m. Patient #11 stands up without assistance and walks accompanied by Emp #27 to the seclusion room.

8:27:14 a.m. Patient #11 goes into the first door "anteroom" of the seclusion room. Emp #27 is standing by the door.

8:27:28 a.m. Emp #1 appears at the doorway of the seclusion room. Emp #27 still present.

8:29:30 a.m. Six (6) additional employees appear on the unit at the seclusion room.

8:30:50 a.m. Emp #11 hands a piece of paper to Emp #1 at the door of the seclusion room.

8:30:59 a.m. Patient #11 walks out of the seclusion room unassisted into Patient #11's room (Room 512).

8:44 a.m. Patient #11 appears in the hallway sitting on the floor, talking on a portable phone.

An additional interview was conducted with Emp # 1 on 12/13/23, at 1:10p.m. Emp #1 was asked to provide information regarding an incident involving Patient #11 on December 11, 2023, at approximately 8:30a.m. Emp #1 stated in part, " I am unsure why this was not reported to me. Staff did not chart the incident or contact the doctor. If [Patient #11] had not called the police, I would not have known about this incident."

An interview was conducted with Emp #19 on 12/14/23, at 9:00 a.m. Emp #19 was asked about the incident involving Patient #11 on 12/11/23. Emp #19 stated, "Initially, I wasn't there. I was in the med room setting up morning medications, this was before the restraints. [Patient #11] was getting vitals by [Emp #21] and [Patient #11] rips off the blood pressure cuff and throws it. [Emp #21] said the Patient was mad. Emp #21 and Emp #2 went to [Patient #11's] room. A few minutes later I heard [Patient #11] screaming so I came out, put on gloves, and took a book away from [Patient #11]. [Emp #27] came up and talked to [Patient #11] and they moved to the seclusion room." Emp #19 was asked to define restraint. Emp #19 stated, "Anything that restricts movement. Emp #19 was asked about the incident involving the blood pressure cuff. Emp #19 stated, "I did not see who threw the blood pressure cuff." Emp #19 asked who contacted the physician following the incident. Emp #19 stated, "Everything happened so fast, I don't know if anyone called the doctor." Emp #19 was shown the video of the incident and asked if [Emp #19] would follow a Patient to their room in this situation. Emp #19 stated, "I would not go to the Patient 's room and shut the door. I would go and check on them and stand in the doorway."

A telephone interview was conducted with Emp #20 on 12/14/23, at 9:45 a.m. Emp #20 was asked about the 12/11/23, incident involving Patient #11. Emp #20 stated, "I saw him throw the blood pressure cuff after [Emp #21] had asked the Patient to speak up. [Patient #11] went to [Patient #11's] room and then came back to nurses' station. I heard Emp #21 and Emp #2 yelling at [Patient #11]. Initially it started as a redirection, then a hold." Emp #20 was asked if there were comments made during the hold. Emp #20 stated, "[Patient #11] said 'You're choking me' and [Emp #3] said 'I'll show you what choking is.' I did not see the choking." Emp #20 was asked about the definition of abuse. Emp #20 stated, "Screaming or yelling at a Patient is not part of our de-escalation training." Emp #20 was asked who called the physician about this incident. Emp #20 stated, "I know that [Emp #2] messaged [Emp #16]."

An interview was conducted with Emp #11 on 12/14/23, at 10:20 a.m. Emp #11 was asked about the incident involving Patient #11 on 12/11/23. Emp #11 stated, "I was at the nurses' station and couldn't really see the vital signs area because there is a large post in the middle. So, I didn't see the ripping off of the blood pressure cuff, I saw {Patient #1] go to [Patient #11's] room. [Emp #21] and [Emp #2] went to the room. [Emp #2] had been sitting at the nurses' station and said 'I'm gonna go check on [Patient #11]'. When [Emp #2] returned [Emp #2] did not say what the conversation was about. [Patient #11] came to the nurses' station and [Patient #11]and [Emp #2] started yelling at each other, it was very noisy. [Emp #21] and [Emp #2] started the hold with [Patient #11]and I started calling security, the manager and paging overhead for additional assistance." Emp #11 was asked if they would enter a Patient 's room and close the door. Emp #11 replied, "I normally stand in the hallway." Emp #11 was shown the video of the incident and asked about the removal of the blood pressure cuff afterwards. Emp #11 stated, '[EMP #21] was not telling the truth." Emp #11 was asked if this incident meets [Emp #11's] definition of an appropriate restraint or hold. Emp #11 stated, "No."

An interview was conducted with Emp #24 on 12/14/23, at 12:49 p.m. Emp #24 was asked about interacting with Patient #11 on 12/11/23.Emp #24 was asked about receiving a request for restraint, Emp #24 stated, "We do not order restraints, we can do the face-to-face evaluation, but we do not order restraints." Emp #24 were asked if they or hospitalists were made aware of hold or restraint. Emp #24 stated, "We were not told about a hold or restraint." Emp #24 was shown the video and asked if when doing a restraint, is a choke hold appropriate. Emp #24 answered, "No."

An interview was conducted with Patient #11 on 12/14/23, at 9:13a.m. Patient #11 stated in part, I was holding on to the nurses' station for dear life, so I didn't get slammed by [EMP #21]. I was dwelling on what they said in my room. I thought about my lawyer and the lawyer's assistant, and they have helped me out in the past, so I wanted to call them for advice. I asked them their names (EMP # 2 and #21). I said I wanted to call my attorney. Someone
grabbed me from behind, not sure who it was at first, they were yelling in my ears, they were kicking me in the back of my calves. [EMP #2] said I thought your legs hurt, I lifted my legs, then someone squeezed me in the Adam's apple, and I said you are choking me. [EMP #21] said that's not choking you, this is and squeezed me harder.

I put my chin down so [EMP #21] couldn't choke me. [EMP #2] kept trying to pry my notebook out of my hands.

Based on document review, medical record review, and staff interview, it was revealed the facility failed to follow all policies and procedures regarding notification of Adult Protective Services (APS) in reporting allegations of abuse in one (1) out of one (1) abuse allegation reported, for Patient #1. This failure has the potential to negatively impact all Patients receiving care at the facility.



Findings include:

A review of the policy, titled "Abuse and Neglect of Incapacitated Adults and Facility Residents," reviewed 05/23/22. The policy states, in pertinent part, ... Procedure ... B. Reporting Mechanism 1. Reporting Responsibility: Any medical, dental or mental health professional or social service worker, who has reasonable cause to believe that an incapacitated adult or facility resident is or has been neglected, abused or placed in an emergency situation, or who observes an incapacitated adult or facility resident being subjected to conditions that are likely to result in abuse, neglect or an emergency situation must immediately report the circumstances by telephone to the West Virginia abuse and neglect hotline at 1-800-352-6513. The telephone report must be followed by a written report within 48 [forty-eight] hours. The reporter may request that his/her name be removed from the report before APS forwards it to the appropriate law enforcement agency, prosecuting attorney, or medical examiner. The Care Management Department can assist with facilitating the process ..."


A review was conducted of state code "§9-6-11. Reporting procedures." The code states, "(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. The department shall, upon receiving any such report, take such action as may be appropriate and shall maintain a record thereof. The department shall receive reports on its 24-hour, seven-day-a-week, toll-free number established to receive calls reporting cases of suspected or known adult abuse or neglect. (b) A copy of any report of abuse, neglect, financial exploitation, or emergency situation shall be immediately filed with the following agencies: (1) The Department of Health and Human Resources; (2) The appropriate law-enforcement agency and the prosecuting attorney, if necessary; or (3) In case of a death, to the appropriate medical examiner or coroner ' s office ..."

A medical record review was conducted for Patient #1. The Patient presented to the facility Emergency Department (ED) on 11/16/23 accompanied by the Patient 's guardian with a complaint of suicidal ideations. A "Nurses Notes" by Emp #10 on 11/16/23 at 3:40 p.m. states, "During admission process Patient stated that [Patient #1] is abused by a staff member at [group] home. Reports that staff member (Staff member name) hits [Patient #1] in the stomach. Patient could not provide any more information than this. No bruising or marks noted during skin assessment. Reported to APS [Adult Protective Services] at 1524 (3:24 p.m.) Spoke to (APS worker name). Intake number: 356110." The Patient was discharged back to the previous residence, which is a group home. The Patient left the facility on 11/21/23 at 11:51 a.m.

May it be noted, there were no written APS reporting form in Patient #1's medical record.

An interview was conducted with Emp #13 on 12/05/23 at approximately 11:00 a.m. Regarding a written APS form, Emp #13 explains they never fill out a form or send anything to APS. They just call the 1-800 hotline and document the reference number. APS then sends them a letter back if they accepted the case or not.