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Based on video footage review, document review and staff interview it was determined the Chief Executive Officer failed to ensure the abuse/neglect and progressive disciplinary policies were followed (patient #1) in one (1) of eleven (11) medical records reviewed (See Tag A 057).

Based on video footage review, document review and staff interview it was determined the Chief Executive Officer (CEO) failed to ensure the abuse/neglect and progressive disciplinary policies were followed (patient #1) in one (1) of eleven (11) medical records reviewed. This failure has the potential for patients who are physically abused to receive care from their perpetrator.

A review of the video recording on 06/22/22 of unit N-1 showed patient #1 rounding the corner of the nursing station at 12:47:02. Licensed Practical Nurse (LPN) #1's back was to the patient and at 12:47:04, patient #1 began punching and hitting LPN #1 in the back and side of the head. Health Service Worker (HSW) #1 rounded the corner at 12:47:04, threw a clipboard and tackled patient #1. LPN #1 scooted with her feet out of the area and is seen holding their head. At 12:47:09, patient #1 is bucking to get HSW #1 off of them. HSW #1 draws back their arm and hits patient #1 with their elbow. Blood can be seen in the floor. HSW #2 arrives to help HSW #1 at 12:47:16 and holds the patient's left arm. The patient's face is turned to the side. At 12:53 p.m., Registered Nurse (RN) #1 is given towels to clean the patient's forehead to assess the injury and the patient was sat up to further assess injury. At 12:54 p.m., patient #1 got out of their hold and hit RN #1 in the head. At 1:02 p.m., Emergency Medical Services (EMS) arrived and patient #1 was placed on a stretcher. At 1:21 p.m., patient #1 was placed in restraints by EMS. At 1:37:50, EMS is seen leaving the unit with patient #1.

Review of the policy titled "Reporting and Investigating Verbal Abuse, Physical Abuse, Neglect, Sexual Harassment of Patients," last revised 10/01/21, states in part: "Abuse of patients, either verbal, physical, or sexual, or by exploitation or neglect, is not tolerated and is considered grounds for disciplinary action up to and including termination ... Physical abuse: W.Va. Code 9-6-1(3)-The infliction or threat of physical or psychological harm, including the use of undue influence or the imprisonment of any patient ... Facility mandatory reports shall make and file Good Faith Reports ... NCC [Nursing Clinical Coordinator] or Administrator shall IMMEDIATELY suspend the alleged perpetrator pending completion of the investigation into the allegations, the findings are reviewed by Administration, and the alleged perpetrator is approved by Administration to return to work or entry into the facility ... The NCC will initiate an investigation by interviewing the alleged perpetrator and reviewing other available evidence ... A referral to LAWV [Legal Aide of West Virginia] of each Good Faith Report shall provide that LAWV must complete its separate investigation and returned to the Administrator within eight (8) days ... The final facility investigation report should be submitted to the CEO [Chief Executive Officer] as soon as practicable ... The CEO or designee will then determine if the complaint is substantiated or unsubstantiated, or unable to be substantiated."

Review of the policy titled "Progressive Correction and Disciplinary Action," last revised 05/16/16, states in part: "Definitions ... gross misconduct-conduct which implies a willful disregard of the employer's interest or a wanton disregard of standards of behavior which the employer has a right to expect of its employees. It includes behavior for which the employee has previously been warned in writing, that further similar conduct could lead to dismissal ... EPA [Employee performance appraisal] is the first place that an employee is informed what is expected of them ... The EPA-2 can be used in conjunction with other tools to document improvement or continued concerns ... Suspension Pending Investigation. Because of a perceived threat of continuing danger to persons or property or to protect the integrity of evidence, it sometimes is necessary for the agency to temporarily relieve an employee of duty while it conducts an investigation when the subject of a criminal indictment or proceeding ... When determining which level of discipline may be appropriate, management should consider the totality of the circumstances, which includes but, is not limited to: the employees' EPA 1, 2, and/or 3, prior disciplinary history, length of tenure, the nature of the employees position ... aggravating or mitigating circumstances, as well as the level of discipline imposed in similar situations ... Suspension: A suspension must be for a specific period of time, which must be clearly stated in the written notification ... Ten (10) day (optional, as determined by the severity of the incident and/or aggravating/mitigating circumstances)."

An interview was conducted on 08/02/22 at 9:20 a.m. with the CEO. When asked how they came to the determination that HSW #1 should be allowed to come back to work, they stated in part, "I read both the internal investigation and the investigation from legal aide. They both were substantiated and APS (Adult Protective Services) unsubstantiated the complaint. I battled with this because (states HSW #1's name) has been a very good contract worker for several years. They have been wonderful with the patients and staff. I discussed this investigation with the (states Director of Nursing's name) to make sure that I was seeing everything correctly. I can retrain people for CCG training, and I can re-educate people on our policy, and since I use the same progressive disciplinary policy on my contract employees as I do state employees, and he had no previous disciplinary action, I believed I made the right decision." When asked if they were contacted about the decision to terminate HSW #1 on Monday, they stated in part, "Yes, I was on vacation, but they contacted me after watching the video and thought it was a violent act and I told them if you feel like it was violent then terminate them." When asked if they themselves had watched the video prior to deciding to allow the worker to come back to work, they stated, "No, but that process will now change."

An interview was conducted on 08/02/22 at 1:20 p.m. with the Assistant CEO. When asked why the decision to terminate HSW #1 after they were allowed to return to work on 07/13/22, they stated in part, "I wasn't a part of the investigation and had not read the report. When you made entrance, I read the reports and felt it was my obligation to watch the video. First, the patient was on 1:1 (one-to-one) and shouldn't be allowed to loop the corner without the HSW so the safety checks were not completed properly. I had the Medical Director and the Physician Assistant, along with the COO (Chief Operating Officer), review the video and we all felt they should be terminated. They concurred the patient was abused by HSW #1 and should never have been allowed to return to work."

Based on medical record review, document review, video footage review and staff interview it was determined the facility failed to follow their abuse and levels of observation policies resulting in physical abuse (patient #1) for one (1) out of eleven (11) medical records reviewed (See Tags A 144 and A 145).

Based on medical record review, document review and staff interview it was determined the facility failed to ensure patient safety checks were completed as ordered (patient #1) in one (1) out of eleven (11) medical records reviewed. This failure has the potential for patients to receive substandard care and observation that may lead to the harm of themselves or others.

A review of the medical record for patient #1 revealed the patient was placed in a physical hold on 06/22/22 from 12:47 p.m. through 1:37 p.m. when they left the hospital with Emergency Medical Services.

A review of the 1:1 (one-to-one) safety check on 06/22/22 for patient #1 revealed the following: At 12:45 p.m., patient #1 was noted to be calm and in the shower; at 1:00 p.m., they were calm and in the shower; at 1:15 p.m., they were calm and in the hallway; and, at 1:30 p.m., they were awake in bed, showing signs of life. It should be noted the initials on these times were not completed by Health Service Worker (HSW) #1 and there was no signature for the initials listed on the back. The safety check further revealed: At 1:45 p.m., patient #1 was awake in bed, showing signs of life; at 2:00 p.m., they were awake in bed, showing signs of life; at 2:15 p.m., they were in the dayroom calm/cooperative, showing signs of life; at 2:30 p.m., they were in the dayroom calm/cooperative, showing signs of life; at 2:45 p.m., they were awake in bed, showing signs of life; at 3:00 p.m., they were awake in bed, showing signs of life; at 3:15 p.m., they were awake in bed, showing signs of life. It should be noted there was no nursing note of the time the patient returned to the unit.

A review of the daily shift assignment sheet revealed patient #1 began 2:1 (two-to-one) safety check at 3:30 p.m. on 06/22/22.

A review of the policy titled "Levels of Observation," last revised 09/17/21, states in part: "One-to-One observation (1:1) ... Documentation of behavior must be made at least every fifteen (15) minutes on the Observation Documentation Sheet ... A patient on this level of observation must be within arm's length of the assigned staff member at all times."

An interview was conducted on 08/02/22 at 1:20 p.m. with the Assistant Chief Executive Officer. They concurred 1:1 observation was not conducted like they were supposed to be.

Based on medical record review, video footage review, document review and staff interview it was determined the facility failed to ensure all patients remained free from abuse (patient #1) in one (1) of eleven (11) medical records reviewed. This failure has the potential to allow patients to be at risk of physical abuse.

Review of the medical record for patient #1 revealed a nursing note on 06/22/22 at 12:47 p.m. that stated in part: "(States patient's name) was in the hallway and ran to a (states staff member's name) and began punching them in the face and head. Pt. [patient] was put in a physical hold by 1:1 [one-to-one] staff. Pt. got a double head laceration when they hit the floor on the right side of their forehead. Pt. was held in a physical hold and [their] wounds assessed. Pressure applied to head laceration. [They were] sat up and the pt. punched another staff in the face. Pt. was given Zyprexa and Benadryl IM per physician orders. They continued to resist being in the physical hold. EMS [Emergency Medical Services] arrived and the pt. was placed on the stretcher and held by staff until EMS was able to obtain an order to utilize their physical restraints at 13:25 [1:25 p.m.]. They were taken off unit by EMS." A restraint and seclusion order was obtained by the Nurse Practitioner at the incident. An Adult Protective Service (APS) order was issued with reference #11652500. Further review of the medical record showed two (2) pictures that were taken after the patient returned from the hospital that revealed two (2) lacerations with sutures to the right forehead.

A review of the video recording on 06/22/22 of unit N-1 showed patient #1 rounding the corner of the nursing station at 12:47:02. Licensed Practical Nurse (LPN) #1's back was to the patient and at 12:47:04, patient #1 began punching and hitting LPN #1 in the back and side of the head. Health Service Worker (HSW) #1 rounded the corner at 12:47:04, threw a clipboard and tackled patient #1. LPN #1 scooted with her feet out of the area and is seen holding their head. At 12:47:09, patient #1 is bucking to get HSW #1 off of them. HSW #1 draws back their arm and hits patient #1 with their elbow. Blood can be seen in the floor. HSW #2 arrives to help HSW #1 at 12:47:16 and holds the patient's left arm. The patient's face is turned to the side. At 12:53 p.m., Registered Nurse (RN) #1 is given towels to clean the patient's forehead to assess the injury and the patient was sat up to further assess injury. At 12:54 p.m., patient #1 got out of their hold and hit RN #1 in the head. At 1:02 p.m., EMS arrived and patient #1 was placed on a stretcher. At 1:21 p.m., patient #1 was placed in restraints by EMS. At 1:37:50, EMS is seen leaving the unit with patient #1.

An APS report was filed on 06/22/22 with allegations of physical abuse. The APS investigation was unsubstantiated. The facility's internal investigation was substantiated. An investigation conducted by the Legal Aide of West Virginia (LAWV) was also substantiated.

A review of HSW #1's personnel filed revealed the staff member was trained in CCG (Crisis Consultant Group) holding for restraints annually. They were suspended on 06/22/22 for allegations of physical abuse during restraints. They were allowed to return to work on 07/13/22.

A review of the policy titled "Reporting and Investigating Verbal Abuse, Physical Abuse, Neglect, Sexual Harassment of Patients," last revised 10/01/21, states in part: "Abuse of patients, either verbal, physical, or sexual, or by exploitation or neglect, is not tolerated and is considered grounds for disciplinary action up to and including termination ... Physical abuse: W.Va. Code 9-6-1(3)-The infliction or threat of physical or psychological harm, including the use of undue influence or the imprisonment of any patient ... Facility mandatory reports shall make and file Good Faith Reports ... NCC [Nursing Clinical Coordinator] or Administrator shall IMMEDIATELY suspend the alleged perpetrator pending completion of the investigation into the allegations, the findings are reviewed by Administration, and the alleged perpetrator is approved by Administration to return to work or entry into the facility ... The NCC will initiate an investigation by interviewing the alleged perpetrator and reviewing other available evidence ... A referral to LAWV of each Good Faith Report shall provide that LAWV must complete its separate investigation and returned to the Administrator within 8 (eight) days ... The final facility investigation report should be submitted to the CEO [Chief Executive Officer] as soon as practicable ... The CEO or designee will then determine if the complaint is substantiated or unsubstantiated, or unable to be substantiated."

On 08/01/22 at 2:35 p.m., the Assistant CEO entered the conference room. They stated in part, "I have reviewed the video from the incident and (states HSW #1's name) is being terminated right now. They should never have been allowed to come back to work and we are going to do what is right. I had the (states Chief Operating Officer's (COO) name) review the video and they agree." It should be noted the CEO was on vacation on 08/01/22.

An interview was conducted on 08/02/22 at 9:20 a.m. with the CEO. When asked how they came to the determination that HSW #1 should be allowed to come back to work, they stated in part, "I read both the internal investigation and the investigation from legal aide. They both were substantiated and APS unsubstantiated the complaint. I battled with this because (states HSW #1's name) has been a very good contract worker for several years. They have been wonderful with the patients and staff. I discussed this investigation with the (states Director of Nursing's name) to make sure that I was seeing everything correctly. I can retrain people for CCG training, and I can re-educate people on our policy, and since I use the same progressive disciplinary policy on my contract employees as I do state employees, and he had no previous disciplinary action, I believed I made the right decision." When asked if they were contacted about the decision to terminate HSW #1 on Monday, they stated in part, "Yes, I was on vacation, but they contacted me after watching the video and thought it was a violent act and I told them if you feel like it was violent then terminate them." When asked if they themselves had watched the video prior to deciding to allow the worker to come back to work, they stated, "No, but that process will now change."

An interview was conducted on 08/02/22 at 1:20 p.m. with the Assistant CEO. When asked again why the decision to terminate HSW #1 after they were allowed to return to work on 07/13/22, they stated in part, "I wasn't a part of the investigation and had not read the report. When you made entrance, I read the reports and felt it was my obligation to watch the video. First the patient was on 1:1 and shouldn't be allowed to loop the corner without the HSW so the safety checks were not completed properly. I had the Medical Director and the Physician Assistant, along with the COO, review the video and we all felt they should be terminated. They concurred the patient was abused by HSW #1."