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Review of clinical records, document review and interview revealed the facility failed to ensure procedures were followed to protect patient's rights to care in a safe setting. The facility failed to ensure a registered nurse accused of physical abuse was promptly removed from access to patients and appropriate authorities notified in one (1) of (1) patients abused (patient #1). This failure creates the potential that an abusive staff member is allowed to continue to provide patient care and may further abuse patients (See tag A 144).

A. Based on review of clinical records, document review and staff interview it revealed the facility failed to ensure procedures were followed to protect patient's rights to care in a safe setting. The facility failed to ensure a registered nurse (RN) accused of physical abuse was promptly removed from access to patients and notify law enforcement. These failures create the potential that an abusive staff member is allowed to continue to provide patient care and may further abuse patients.

Findings include:

1. Review of patient #1's clinical record revealed he/she is a twenty-nine (29) year-old with a diagnosis of Unspecified Mood Disorder. RN #1 noted patient #1 was in a hold (a physical restraint where staff holds parts of the patient's body to prevent movement) from 10:25 p.m. to 10:40 p.m. on 10/6/21. RN #1's notes stated in part: "PT's (patient's) nose had begun to bleed from injuries sustained struggling with staff during supine hold... PT had nosebleed/lip bleed from injuries sustained during struggle with staff during 2-person supine hold. Patient asked for and was given an ice pack to hold against injured area." Time stamps on RN #1's notes showed he/she charted on patient #1's clinical record after the hold (from 10/7/21 from 12:37 a.m. to 2:16 a.m.)

2. Review of a document from St. Mary's Medical Center titled, "General Medicine (Adult) - Provider Note) Collected on 10/7/21 11:37" for patient #1 revealed, "Medical Decision Making and Diagnosis Final Diagnostic Impression 1. Nasal Bone Fracture, 2. Closed Head injury."

3. Review of a document titled, "RIVER PARK HOSPITAL POLICY AND PROCEDURE Department: Administration Subject: Identification/Reporting of Abuse," revised 11/20, revealed: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

4. An interview was conducted on 11/8/21 at 12:50 p.m. with the Nurse Manager (NM) after she reviewed the videotape with the State surveyor that showed RN #1 punching patient #1 on 10/6/21 at 10:20 p.m. He/she stated MHT #1 and MHT #2 told NS #1 separately about RN #1 punching patient #1. These reports were made to NS #1 between 10:30 p.m. and midnight. NS #1 told NS #2, who was the oncoming supervisor, what happened. NS #2 then contacted the NM and NS #1 contacted the Chief Nursing Officer (CNO) (at the same time). This was at midnight. He/she is sure of the time because he/she looked at the clock when he/she received the call.

5. A phone interview was conducted on 11/8/21 from 1:00 p.m. to 1:30 p.m. with NS #1. He/she stated he/she was on Three West (3W) on 10/6/21 when RN #1 abused patient #1. He/she did not witness the abuse. After the incident and after shift change, MHT #2 called him/her on the phone and told him/her he/she witnessed RN #1 punch patient #1 during the hold. He/she told her he/she was sure of what he/she witnessed and MHT #1 also witnessed it. A few minutes later MHT #1 came to him/her on the unit and told him/her, "Hey, I wanted to let you know that RN #1 punched patient #1 and that's why he/she was bleeding." NS #1 then stated, "After I was told, I kind of, (here she paused) I don't remember doing anything specific at that time." He/she told the oncoming supervisor, NS #2 what had happened and NS #2 told him/her what to do. Both of them called administrative personnel and NS #2 then told him/her that RN #1 needed to leave. Then NS #2 informed RN #1 he/she had to leave. When asked about contacting the Administrator on Call, the NM and the CNO, he/she stated he/she knew notification had to occur quickly, "But somehow I had it in my head I had an hour to call these people." Nothing prevented him/her from making the calls immediately but he/she waited to get direction from NS #2, who had been a supervisor longer. When she went to give NS #2 report about the alleged abuse, she left RN #1 working on the unit. Shift change for NS is between 11:00 p.m. and 11:30 p.m. but, "I feel like I was on the unit closer to 11:30 p.m. before I went down to NS #2."

6. A phone interview was conducted on 11/8/21 at 2:40 p.m. with MHT #1. He/she stated he/she saw RN #1 hit patient #1 during a physical hold. He/she told NS #1 before he/she left that RN #1 punched patient #1 during the hold. He/she goes off shift at 11:30 p.m. but he/she can't pinpoint the time he/she told NS #1 because, "There was a lot going on." He/she told NS #1 before he/she left, "You're going to want to look at those cameras because you're not going to like what you see." When he/she left the unit, RN #1 was still working on the unit.

7. An interview was conducted on 11/8/21 at 3:08 p.m. with MHT #2. He/she saw RN #1 hit patient #1 during a physical hold. MHT #2 knew he/she had to report it, so after he/she left the building MHT #2 called and told NS #1. He/she didn't report it immediately because he/she didn't want to "stir things up on the unit." MHT #2 thinks he/she is a mandated reporter and he/she has four (4) hours to report abuse.

8. An interview was conducted on 11/9/21 at 8:21 a.m. with the CNO. The Patient Advocate was present. The CNO acknowledged there was too much time between the MHTs witnessing the abuse and reporting it to the NS. The CNO acknowledged there was too much time between the NS being made aware of the alleged abuse and notification to administration. The CNO acknowledged RN #1 should have immediately had his/her keys taken, been removed from the unit and escorted from the building. The CNO concurred these events created an unacceptably slow response to the situation.

During the interview conducted on 11/9/21 at 8:21 a.m. with the CNO the State surveyor informed him/her the facility was obligated to immediately report the assault to law enforcement. The CNO requested clarification in the form of reference to a law. The CNO acknowledged notification to law enforcement had not occurred. Per facility policy, notification to Adult Protective Services (APS) and the Office of Health Facility Licensure and Certification (OHFLAC) was sufficient. The facility expects those agencies to follow up with notification to law enforcement as needed. The State surveyor assured her the facility had an obligation to notify law enforcement immediately. The CNO again requested the regulatory reference.

9. An interview was conducted on 11/9/21 at 3:00 p.m. with NS #2. NS #2 stated he/she informed RN #1 he/she had to leave but he/she must not have understood and started charting. NS #2 then told RN #1 he/she could not stay and chart. "Me myself, I would not have walked off the unit and left (RN #1) working the unit after I got reports from the MHTs of the abuse."

10. An interview was conducted on 11/9/21 at 3:45 p.m. with the CNO. The Patient Advocate was present. When asked if staff who have abuse alleged against them should have their keys taken and be escorted out of the building, the CNO responded, "That should have been the process." RN #1 was permitted to stay to chart although the instructions given to the NS by administration was for RN #1 to leave. "The best option would be for RN #1 to leave and the supervisor do all the charting because she/he would have been involved in all the codes." RN #1 did all his/her charting up until 10/7/21 at 2:16 a.m. on 3W (the unit where the alleged abuse occurred). This was verified by video.

11. An interview was conducted on 11/10/21 at 8:55 a.m. with the CNO. The CNO stated law enforcement was not notified by the facility of the assault until 10/9/21 (after the surveyor left the building at 4:30 p.m.)

B. Based on review of clinical records, document review and staff interview it revealed the facility failed to ensure procedures were followed to protect patient's rights to care in a safe setting. The facility failed to ensure a registered nurse (RN) accused of physical abuse was promptly removed from access to patients, and notify law enforcement in one (1) of (1) patients abused (patient #1). These failures create the potential that an abusive staff member is allowed to continue to provide patient care and may further abuse patients.

Findings include:

1. Review of patient #1's clinical record revealed he/she is a twenty-nine (29) year-old with a diagnosis of Unspecified Mood Disorder. Registered Nurse (RN) #1 noted patient #1 was in a hold (a physical restraint where staff holds parts of the patient's body to prevent movement) from 10:25 p.m. to 10:40 p.m. on 10/6/21. RN #1's notes stated in part: "PT's (patient's) nose had begun to bleed from injuries sustained struggling with staff during supine hold... PT had nosebleed/lip bleed from injuries sustained during struggle with staff during 2-person supine hold. Patient asked for and was given an ice pack to hold against injured area." Time stamps documented by RN #1, on 10/07/21 at 12:37 a.m. and 2:16 a.m. showed he/she charted on patient #1's clinical record after the hold. Further review revealed a provider note from St. Mary ' s hospital on 10/07/21 at 11:37 a.m. Diagnosis Final Diagnostic Impression 1. Nasal Bone Fracture, 2. Closed Head injury."

2. Review of a document titled, "Administration Subject: Identification/Reporting of Abuse," revised 11/20, revealed: "The staff allegedly involved in the abuse will be removed from the schedule until such time as any investigation has been completed."

3. An interview was conducted on 11/8/21 at 12:50 p.m. with the Nurse Manager (NM) after she reviewed the videotape with the State surveyor that showed RN #1 punching patient #1 on 10/6/21 at 10:20 p.m. He/she stated MHT #1 and MHT #2 told NS #1 separately about RN #1 punching patient #1. These reports were made to NS #1 between 10:30 p.m. and midnight. NS #1 told NS #2, who was the oncoming supervisor, what happened. NS #2 then contacted the NM and NS #1 contacted the Chief Nursing Officer (CNO) (at the same time). This was at midnight. He/she is sure of the time because he/she looked at the clock when he/she received the call.

4. A phone interview was conducted on 11/8/21 from 1:00 p.m. to 1:30 p.m. with NS #1. He/she stated he/she was on Three West (3W) on 10/6/21 when RN #1 abused patient #1. He/she did not witness the abuse. After the incident and after shift change, MHT #2 called him/her on the phone and told him/her he/she witnessed RN #1 punch patient #1 during the hold. He/she told her he/she was sure of what he/she witnessed and MHT #1 also witnessed it. A few minutes later MHT #1 came to him/her on the unit and told him/her, "Hey, I wanted to let you know that RN #1 punched patient #1 and that's why he/she was bleeding." NS #1 then stated, "After I was told, I kind of, (here she paused) I don't remember doing anything specific at that time." He/she told the oncoming supervisor, NS #2 what had happened, and NS #2 told him/her what to do. Both of them called administrative personnel and NS #2 then told him/her that RN #1 needed to leave. Then NS #2 informed RN #1 he/she had to leave. When asked about contacting the Administrator on Call, the NM and the CNO, he/she stated he/she knew notification had to occur quickly, "But somehow I had it in my head I had an hour to call these people." Nothing prevented him/her from making the calls immediately, but he/she waited to get direction from NS #2, who had been a supervisor longer. When she went to give NS #2 report about the alleged abuse, she left RN #1 working on the unit. Shift change for NS is between 11:00 p.m. and 11:30 p.m. but, "I feel like I was on the unit closer to 11:30 p.m. before I went down to NS #2."

5. A phone interview was conducted on 11/8/21 at 2:40 p.m. with MHT #1. He/she stated he/she saw RN #1 hit patient #1 during a physical hold. He/she told NS #1 before he/she left that RN #1 punched patient #1 during the hold. He/she goes off shift at 11:30 p.m. but he/she can't pinpoint the time he/she told NS #1 because, "There was a lot going on." He/she told NS #1 before he/she left, "You're going to want to look at those cameras because you're not going to like what you see." When he/she left the unit, RN #1 was still working on the unit.

6. An interview was conducted on 11/8/21 at 3:08 p.m. with MHT #2. He/she saw RN #1 hit patient #1 during a physical hold. MHT #2 knew he/she had to report it, so after he/she left the building MHT #2 called and told NS #1. He/she didn't report it immediately because he/she didn't want to "stir things up on the unit." MHT #2 thinks he/she is a mandated reporter, and he/she has four (4) hours to report abuse.

7. An interview was conducted on 11/9/21 at 8:21 a.m. with the CNO. The Patient Advocate was present. The CNO acknowledged there was too much time between the MHTs witnessing the abuse and reporting it to the NS. The CNO acknowledged there was too much time between the NS being made aware of the alleged abuse and notification to administration. The CNO acknowledged RN #1 should have immediately had his/her keys taken, been removed from the unit, and escorted from the building. The CNO concurred these events created an unacceptably slow response to the situation.

8. During the interview conducted on 11/9/21 at 8:21 a.m. with the CNO the State surveyor informed him/her the facility was obligated to immediately report the assault to law enforcement. The CNO requested clarification in the form of reference to a law. The CNO acknowledged notification to law enforcement had not occurred. Per facility policy, notification to Adult Protective Services (APS) and the Office of Health Facility Licensure and Certification (OHFLAC) was sufficient. The facility expects those agencies to follow up with notification to law enforcement as needed. The State surveyor assured her the facility had an obligation to notify law enforcement immediately WV Code 9-6-11(b)(2), was given to the CNO.

9. An interview was conducted on 11/9/21 at 3:00 p.m. with NS #2. NS #2 stated he/she informed RN #1 he/she had to leave but he/she must not have understood and started charting. NS #2 then told RN #1 he/she could not stay and chart. "Me myself, I would not have walked off the unit and left (RN #1) working the unit after I got reports from the MHTs of the abuse."

10. An interview was conducted on 11/9/21 at 3:45 p.m. with the CNO. The Patient Advocate was present. When asked if staff who have abuse alleged against them should have their keys taken and be escorted out of the building, the CNO responded, "That should have been the process." RN #1 was permitted to stay to chart although the instructions given to the NS by administration was for RN #1 to leave. "The best option would be for RN #1 to leave and the supervisor do all the charting because she/he would have been involved in all the codes." RN #1 did all his/her charting up until 10/7/21 at 2:16 a.m. on 3W (the unit where the alleged abuse occurred). This was verified by video.

11. An interview was conducted on 11/10/21 at 8:55 a.m. with the CNO. The CNO stated law enforcement was not notified by the facility of the assault until 11/9/21.

Based on review of documents and interview it was revealed the facility failed to follow their nursing staffing matrix. This failure creates the potential patients will receive inadequate or inappropriate care, resulting in harm or injury.

Findings include:

1. Review of documents titled, "River Park Hospital Variable Staffing Plan Department 3 West Adult Chronic" states in part, One (1) registered nurse (RN) and one (1) licensed practical nurse for each shift. A review of staffing schedules revealed for day, evening and night shifts from 10/1/21 through 10/8/21 revealed LPNs were not staffed according to matrix for thirteen (13) out of twenty-four (24) shifts. The census during that time period was consistently twenty-eight (28), reflecting every bed was full.

2. An interview was conducted with the CNO on 10/10/21 at 8:25 a.m. The CNO revealed nursing services staffing does not always follow the staffing matrix and is adjusted according to the nursing supervisor's discretion. This means an LPN may not be staffed on the unit as required by the staffing matrix. The CNO declined to acknowledge the matrix is supposed to be followed to ensure staffing of personnel is adequate to meet patient needs.