HospitalInspections.org

C. Based on document review, policy review and staff interviews it was determined the governing body failed to investigate grievances or appoint a grievance committee with a list of personnel responsible for investigating grievances in four hundred and seventeen (417) out of four hundred and seventeen (417) grievances filed in the hospital from January 2019 through January 2020. This failure denies the patients admitted to the facility and their representatives to file a grievance and have an investigation completed.

Findings include:

1. Review of five (5) adult protective orders revealed the facility does not complete their own investigations and relies on the Legal Aide Patient Advocate to complete an investigation.

2. Review of the governing board bylaws states in part: "Treatment at Mildred Bateman Hospital shall be in compliance with applicable standards of The Joint Commission on Accreditation of Healthcare Organizations, The Center for Medicare and Medicaid Services...and state and federal laws."

3. Review of the governing body meeting minutes from January 2019 through present revealed the governing body does not complete investigations of grievances nor is their a grievance committee that has been approved in writing with members of the committee named.

4. An interview was conducted with the Chief Executive Officer (CEO) on 02/05/20 at 9:30 a.m. who is a voting member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process, he stated in part: "I think the meeting was the same time we completed policies." He was asked to please find the meeting minutes where the governing body voted on the decision to make a grievance committee and the personnel responsible.

5. An interview was conducted with the Assistant Chief Medical Officer on 02/05/20 at 12:50 p.m. who is a member of the governing body. When asked how often he attends the governing body meetings he stated in part: "I've attended almost all of them since I was a resident here and continued after I began working here." When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that being a part of any meeting but completing our own investigations and the advocate completing theirs is a great idea that will be beneficial to all patients."

6. An interview was conducted with the Director of Human Resources on 02/05/20 at 3:00 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, not in the three (3) years I have been here."

7. A telephone interview was conducted with the Chief of Staff on 02/05/20 at 4:38 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that occurring." When asked if he attends all meetings he stated in part: "I attend most but if I can't, my assistant attends and fills me in on what happens."

8. An interview was conducted with the CEO on 02/06/20 at 11:30 a.m. prior to exit. When asked if he had found the meeting minutes with the vote on a grievance committee he stated in part: "No, there wasn't any."

C. Based on document review and staff interviews it was determined the governing body failed to monitor nursing contracted services in two (2) of two (2) contracted nurses with allegations of abuse by a patient (patients #1 and 9). This failure allows all patients who have a contracted nurse to be potentially abused by contracted staff.

Findings include:

1. Review of adult protective order for patient #1 revealed it was filed on behalf of the patient with a complaint of verbal abuse that allegedly happened on 01/09/20 by contracted Registered Nurse (RN) #1. The adult protective order was delayed until 01/14/20 and was then given to Legal Aide Patient Advocate to complete on 01/15/20. The complaint was not investigated by the governing body or a grievance committee.

2. Review of adult protective order for patient #9 revealed it was filed on behalf of the patient with a complaint of physical abuse that allegedly happened on 07/25/19 by contracted RN #1. The investigation was given to the Legal Aide Patient Advocate on 07/29/19. The complaint was not investigated by the governing body or a grievance committee.

3. Review of the Governing Board Bylaws states in part: "Treatment at Mildred Bateman Hospital shall be in compliance with applicable standards of The Joint Commission on Accreditation of Healthcare Organizations, The Center for Medicare and Medicaid Services...and state and federal laws."

4. Review of the governing body meeting minutes from January 2019 through present revealed the governing body does not complete investigations of grievances nor is there a grievance committee that has been approved in writing with members of the committee named.

5. An interview was conducted with the Chief Executive Officer (CEO) on 02/05/20 at 9:30 a.m. who is a voting member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process, he stated in part: "I think the meeting was the same time we completed policies." He was asked to please find the meeting minutes where the governing body voted on the decision to make a grievance committee and the personnel responsible.

6. An interview was conducted with the Assistant Chief Medical Officer on 02/05/20 at 12:50 p.m. who is a member of the governing body. When asked how often he attends the governing body meetings he stated in part: "I've attended almost all of them since I was a resident here and continued after I began working here." When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that being a part of any meeting but completing our own investigations and the advocate completing theirs is a great idea that will be beneficial to all patients."

7. An interview was conducted with the Director of Human Resources on 02/05/20 at 3:00 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, not in the three (3) years I have been here."

8. A telephone interview was conducted with the Chief of Staff on 02/05/20 at 4:38 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that occurring." When asked if he attends all meetings he stated in part: "I attend most but if I can't, my assistant attends and fills me in on what happens."

9. An interview was conducted with the CEO on 02/06/20 at 11:30 a.m. prior to exit. When asked if he had found the meeting minutes with the vote on a grievance committee he stated in part: "No, there wasn't any."

C. Based on document review and staff interviews it was determined the governing body failed to monitor nursing contracted services in two (2) of two (2) contracted nurses with allegations of abuse by a patient (patients #1 and 9). This failure allows all patients who have a contracted nurse to be potentially abused by the contracted staff.

Findings include:

1. Review of adult protective order for patient #1 revealed it was filed on behalf of the patient with a complaint of verbal abuse that allegedly happened on 01/09/20 by contracted Registered Nurse (RN) #1. The adult protective order was delayed until 01/14/20 and was then given to Legal Aide Patient Advocate to complete on 01/15/20. The complaint was not investigated by the governing body or a grievance committee.

2. Review of adult protective order for patient #9 revealed it was filed on behalf of the patient with a complaint of physical abuse that allegedly happened on 07/25/19 by contracted RN #1. The investigation was given to the Legal Aide Patient Advocate on 07/29/19. The complaint was not investigated by the governing body or a grievance committee.

3. Review of the Governing Board Bylaws states in part: "Treatment at Mildred Bateman Hospital shall be in compliance with applicable standards of The Joint Commission on Accreditation of Healthcare Organizations, The Center for Medicare and Medicaid Services...and state and federal laws."

4. Review of the governing body meeting minutes from January 2019 through present revealed the governing body does not complete investigations of grievances nor is there a grievance committee that has been approved in writing with members of the committee named.

5. An interview was conducted with the Chief Executive Officer (CEO) on 02/05/20 at 9:30 a.m. who is a voting member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process, he stated in part: "I think the meeting was the same time we completed policies." He was asked to please find the meeting minutes where the governing body voted on the decision to make a grievance committee and the personnel responsible.

6. An interview was conducted with the Assistant Chief Medical Officer on 02/05/20 at 12:50 p.m. who is a member of the governing body. When asked how often he attends the governing body meetings he stated in part: "I've attended almost all of them since I was a resident here and continued after I began working here." When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that being a part of any meeting but completing our own investigations and the advocate completing theirs is a great idea that will be beneficial to all patients."

7. An interview was conducted with the Director of Human Resources on 02/05/20 at 3:00 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, not in the three (3) years I have been here."

8. A telephone interview was conducted with the Chief of Staff on 02/05/20 at 4:38 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that occurring." When asked if he attends all meetings he stated in part: "I attend most but if I can't, my assistant attends and fills me in on what happens."

9. An interview was conducted with the CEO on 02/06/20 at 11:30 a.m. prior to exit. When asked if he had found the meeting minutes with the vote on a grievance committee he stated in part: "No, there wasn't any."

C. An Immediate Jeopardy (IJ) was called on 2/5/20 at 2:30 p.m. and was abated on 2/5/20 at 8:40 p.m.

A. Noncompliance: The hospital failed to investigate allegations of abuse in a timely manner on two (2) separate occasions involving the same intellectual development disorder (IDD) patient by one individual staff member resulting in failure to complete and file an adult protective services (APS) form within forty-eight (48) hours of knowledge of the events. These failures resulted in delays of investigations and corrective actions.

The first incident was reported 1/9/20 and alleged the abuser made comments about using injections in a threatening manner. Mandatory reporters witnessed this event. The hospital failed to file an APS report and begin an investigation until 1/15/20. The alleged abuser was permitted to return to work before the report of investigation was formally provided to the hospital. The hospital did not perform an investigation separate from the Patient Advocate's.

The above failure to conduct an independent investigation resulted in a failure to discover an alleged abusive incident by the same staff member which occurred before the initial incident. Although the staff member, who is a mandatory reporter, reported this incident internally, no APS form was filed and no investigation was done.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: The hospital's failure to file APS reports in a time frame required by law, forty-eight (48) hours, resulted in a delay in investigation into the incidents. The report of the Patient Advocate's complete investigation was not given to the facility prior to returning the accused staff member to duty on Unit Three (3). These results were not provided to the facility until 2/3/20, the date of State surveyors entrance. This resulted in the staff member returning to work for two (2) days (1/28/20 and 1/29/20) and exposing the patients to a potentially abusive staff member.

C. Need for Immediate Action: Immediate action must be made to ensure APS is notified within the time mandated by law. All mandatory reporters must submit an APS form for alleged incidents of abuse/neglect so immediate action is taken to protect the patients and conduct a thorough investigation. These failures could result in serious harm or serious impairment to patients.

Based on interviews, clinical record reviews and document reviews it was determined the hospital failed to promote and protect patient rights. The hospital failed to notify patients and guardians of grievances and complaints. The hospital failed to appoint a committee to investigate, measure and track incidents of grievances and complaints. The hospital failed to ensure care in a safe setting by failing to conduct mandatory reporting within forty-eight hours of knowledge of the allegation of abuse which occurred 1/7/20 and 1/9/20. The hospital failed to conduct an investigation independent of the Patient Advocate in two (2) out of two (2) incidents of alleged abuse by RN #1 before a full hospital investigation was conducted. RN #1 was returned to duty on 1/28/20 before a hospital investigation was completed on both these allegations of abuse. In addition, when APS reports were filed on three (3) patients in January 2020 (patients #1, 10 and 32) the hospital failed to notify their guardians. These three (3) patients lacked capacity. These failures place patients at risk for serious injury or harm.

C. Based on review of documents it was determined in three (3) out of three (3) patient grievances (patients #1, 10 and 32) reported to the Adult Protected Services (APS), the guardians were not notified. These patients lacked capacity. This places all patients who lack capacity at risk for their guardians to be unaware of the patient's status resulting in serious harm or injury.

Findings include:

1. A review of documents relevant to APS reports filed for patients #1 (case #200120), #10 (case #200135) and #32(case #191236) in January 2020 revealed the hospital failed to notify guardians of the allegations. In all three (3) cases the patients lacked capacity.

C. Based on review of interviews, clinical record reviews and document reviews it was determined the hospital failed to identify and investigate a grievance filed for patient #1. This grievance, which was for alleged abuse that occurred on 1/9/20, was not reported to Adult Protective Services (APS) within the forty-eight (48) hour time frame required by mandatory reporters. Within the investigation of the 1/9/20 incident by the Patient Advocate, a second alleged abuse that occurred on 1/7/20 by Registered Nurse (RN) #1 was reported. The mandatory reporters failed to report this incident when it occurred. The hospital failed to conduct an investigation independent of the Patient Advocate's. This failure to report and conduct an independent investigation resulted in the second incident of alleged abuse that occurred 1/7/20 to not be reported or investigated. These failures place all patients at risk for serious harm or injury.

Findings include:

1. An interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Director of Human Resources (DHR) and the Assistant Chief Executive Officer (ACEO) on 2/3/20 at 11:30 a.m. During the interview the ACEO revealed RN #1 was suspended as soon as administration received report on 1/14/19 that there was an incident of alleged abuse by RN #1 from 1/9/20.

2. An interview was conducted with the Patient Advocate on 2/4/20 at 11:55 a.m. She revealed she has the authority to investigate any allegations of abuse which occur beyond the case she is investigating. The Patient Advocate acknowledged she received a report from the Behavioral Psychologist when she was interviewed on 1/20/20 that the Behavioral Psychologist told her about an incident of possible abuse which occurred on 1/7/20. The Patient Advocate then told surveyors about the incident which she included in her report dated 2/3/20. This incident was separate from the incident she was investigating from 1/9/20 but involved the same nurse, RN #1. When questioned by the surveyors if she had the authority to start an investigation into the 1/7/20 allegation when she received it, she responded yes. The Patient Advocate stated she feels she should have done this.

3. An interview was conducted with the Chief Executive Officer (CEO) on 2/4/20 at 2:00 p.m. He stated the full written report was not received from the Patient Advocate until 2/3/20. The CEO stated before that date he had no information about the investigation, even from RN #3, who was involved in the investigation. He stated he conducted his own investigation after the advocate's investigation. The CEO stated based on his investigation and in part: "On gut instinct" he decided to terminate RN #1. The termination did not occur until 1/29/19.

4. An interview was conducted with the ADON on 2/5/20 at 10:20 a.m. The ADON revealed she called him and returned him to duty on 1/27/20 after she was called by the DHR and informed the Patient Advocate had advised her the allegation of abuse was unsubstantiated. She revealed patient #1 worked 1/28/20 and 1/29/20. The ADON stated she was instructed by the DHR on 1/29/20 to terminate RN #1, take his badge and keys and tell him he must leave the premises. She did this after RN #1 worked his full shift on 1/29/20. She revealed she asked the DHR why he was terminated and received no answer. She revealed she usually must terminate without knowing the reason and she thinks this is information she needs.

5. A review of document titled "Mildred Mitchell-Bateman Hospital Incident Report" for abuse which allegedly occurred on 1/9/20 showed the hospital did not suspend the accused employee (RN #1) until 1/14/20. The date the APS report was filed was 1/14/20. A review of document (untitled) revealed RN #1 was returned to duty on 1/28/20 and worked two (2) days (1/28/20 and 1/29/20). No investigation of the incident by the hospital was recorded.

6. A review of document titled "Mildred Mitchell-Bateman Hospital Nursing Administration APS Investigation Check-Off List" revealed an allegation of abuse by RN #1 on patient #31 occurred 7/27/19. RN #1 was suspended on that date. A report from the Patient Advocate dated 8/1/19 stated in part: "The allegation is unsubstantiated." RN #1 was returned to duty without a full investigation by the hospital.

7. A review of policy titled "Patient's Rights and Responsibilities," effective date 9/24/19, revealed patients have the right in part: "12. To be free from verbal, mental, physical, and sexual abuse; harassment ..."

C. Based on interviews, clinical record reviews and document reviews it was determined the hospital failed to ensure patient rights. The hospital failed to report allegations of abuse within forty-eight hours of knowledge of the abuse. Mandatory reporters did not report the abuse. The hospital failed to conduct investigations independent of the Patient Advocate's. The hospital failed to protect patients from exposure to staff alleged to have caused neglect or abuse until their investigation was completed. This causes the potential for all patients to experience serious harm or injury.

Findings include:

1. An interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Director of Human Resources (DHR) and the Assistant Chief Executive Officer (ACEO) on 2/3/20 at 11:30 a.m. During the interview the ACEO revealed RN #1 was suspended as soon as administration received report on 1/14/19 that there was an incident of alleged abuse by RN #1 from 1/9/20.

2. An interview was conducted with the Patient Advocate on 2/4/20 at 11:55 a.m. She revealed she has the authority to investigate any allegations of abuse which occur beyond the case she is investigating. The Patient Advocate acknowledged she received a report from the Behavioral Psychologist when she was interviewed on 1/20/20 that the Behavioral Psychologist told her about an incident of possible abuse which occurred on 1/7/20. The Patient Advocate then told surveyors about the incident which she included in her report dated 2/3/20. This incident was separate from the incident she was investigating from 1/9/20 but involved the same nurse, RN #1. When questioned by the surveyors if she had the authority to start an investigation into the 1/7/20 allegation when she received it, she responded yes. The Patient Advocate stated she feels she should have done this.

3. An interview was conducted with the Chief Executive Officer (CEO) on 2/4/20 at 2:00 p.m. He stated the full written report was not received from the Patient Advocate until 2/3/20. The CEO stated before that date he had no information about the investigation, even from RN #3, who was involved in the investigation. He stated he conducted his own investigation after the advocate's investigation. The CEO stated based on his investigation and in part: "On gut instinct" he decided to terminate RN #1. The termination did not occur until 1/29/19.

4. An interview was conducted with the ADON on 2/5/20 at 10:20 a.m. The ADON revealed she called him and returned him to duty on 1/27/20 after she was called by the DHR and informed the Patient Advocate had advised her the allegation of abuse was unsubstantiated. She revealed patient #1 worked 1/28/20 and 1/29/20. The ADON stated she was instructed by the DHR on 1/29/20 to terminate RN #1, take his badge and keys and tell him he must leave the premises. She did this after RN #1 worked his full shift on 1/29/20. She revealed she asked the DHR why he was terminated and received no answer. She revealed she usually must terminate without knowing the reason and she thinks this is information she needs.

5. A review of document titled "Mildred Mitchell-Bateman Hospital Incident Report" for abuse which allegedly occurred on 1/9/20 showed the hospital did not suspend the accused employee (RN #1) until 1/14/20. The date the APS report was filed was 1/14/20. A review of document (untitled) revealed RN #1 was returned to duty on 1/28/20 and worked two (2) days (1/28/20 and 1/29/20). No investigation of the incident by the hospital was recorded.

6. A review of document titled "Mildred Mitchell-Bateman Hospital Nursing Administration APS Investigation Check-Off List" revealed an allegation of abuse by RN #1 on patient #31 occurred 7/27/19. RN #1 was suspended on that date. A report from the Patient Advocate dated 8/1/19 stated in part: "The allegation is unsubstantiated." RN #1 was returned to duty without a full investigation by the hospital.

7. A review of policy titled "Patient's Rights and Responsibilities," effective date 9/24/19, revealed patients have the right in part: "12. To be free from verbal, mental, physical, and sexual abuse; harassment ..."

A. Based on observation and interviews it was revealed the hospital failed to provide care in a safe setting by not changing the shower knobs to prevent ligature risks in twenty-five (25) of forty-five (45) patient rooms (Rooms 212, 301, 302, 303, 304, 305, 306, 310, 311, 312, 313, 314, 315, 401, 402, 403, 404, 405, 406, 410, 411, 412, 413, 414 and 415). The failure to change the shower knobs in the patient rooms has the potential to adversely affect all patients housed in the above-mentioned rooms.

Findings include:

1. A tour conducted on 12/17/19 at approximately 1:20 p.m. revealed the hot/cold mixer knobs on the showers in rooms 302, 304, 404 and 415 have a space between the knob and the shower casing big enough for a finger to fit in which could potentially cause a ligature risk.

2. An interview conducted with the Chief Executive Officer (CEO) and Assistant CEO on 12/17/19 at approximately 2:40 p.m. revealed they had a different piece of equipment for the showers and were working towards having all fixtures replaced by 2/1/20.

3. An interview conducted with the CEO and Assistant CEO on 12/17/19 at approximately 3:55 p.m. revealed twenty-five (25) of the forty-five (45) rooms (rooms 212, 301, 302, 303, 304, 305, 306, 310, 311, 312, 313, 314, 315, 401, 402, 403, 404, 405, 406, 410, 411, 412, 413, 414 and 415) on units two (2), three (3) and four (4) needed to be updated with shower knobs which did not pose a ligature risk. The CEO and Assistant CEO concurred with the above findings and were working on a plan to remove any patients who were a suicide risk from the above- mentioned rooms or make them a one to one (1:1) observation and prioritize the completion of work on the shower knobs sooner than 2/1/20.


(C.) B. Based on interviews, clinical record reviews and document reviews it was determined the hospital failed to provide care in a safe setting. The hospital failed to do investigations of allegations of abuse independent of the Patient Advocate's in two (2) cases of alleged abuse. The hospital failed to protect patients from exposure to staff alleged to have committed the abuse until their investigation was completed. This failure causes the potential for all patients to experience serious harm or injury.

Findings include:

1. An interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Director of Human Resources (DHR) and the Assistant Chief Executive Officer (ACEO) on 2/3/20 at 11:30 a.m. During the interview the ACEO revealed RN #1 was suspended as soon as administration received report on 1/14/19 that there was an incident of alleged abuse by RN #1 from 1/9/20.

2. An interview was conducted with the Patient Advocate on 2/4/20 at 11:55 a.m. She revealed she has the authority to investigate any allegations of abuse which occur beyond the case she is investigating. The Patient Advocate acknowledged she received a report from the Behavioral Psychologist when she was interviewed on 1/20/20 that the Behavioral Psychologist told her about an incident of possible abuse which occurred on 1/7/20. The Patient Advocate then told surveyors about the incident which she included in her report dated 2/3/20. This incident was separate from the incident she was investigating from 1/9/20 but involved the same nurse, RN #1. When questioned by the surveyors if she had the authority to start an investigation into the 1/7/20 allegation when she received it, she responded yes. The Patient Advocate stated she feels she should have done this.

3. An interview was conducted with the Chief Executive Officer (CEO) on 2/4/20 at 2:00 p.m. He stated the full written report was not received from the Patient Advocate until 2/3/20. The CEO stated before that date he had no information about the investigation, even from RN #3, who was involved in the investigation. He stated he conducted his own investigation after the advocate's investigation. The CEO stated based on his investigation and in part: "On gut instinct" he decided to terminate RN #1. The termination did not occur until 1/29/19.

4. An interview was conducted with the ADON on 2/5/20 at 10:20 a.m. The ADON revealed she called him and returned him to duty on 1/27/20 after she was called by the DHR and informed the Patient Advocate had advised her the allegation of abuse was unsubstantiated. She revealed patient #1 worked 1/28/20 and 1/29/20. The ADON stated she was instructed by the DHR on 1/29/20 to terminate RN #1, take his badge and keys and tell him he must leave the premises. She did this after RN #1 worked his full shift on 1/29/20. She revealed she asked the DHR why he was terminated and received no answer. She revealed she usually must terminate without knowing the reason and she thinks this is information she needs.

5. A review of document titled "Mildred Mitchell-Bateman Hospital Incident Report" for abuse which allegedly occurred on 1/9/20 showed the hospital did not suspend the accused employee (RN #1) until 1/14/20. The date the APS report was filed was 1/14/20. A review of document (untitled) revealed RN #1 was returned to duty on 1/28/20 and worked two (2) days (1/28/20 and 1/29/20). No investigation of the incident by the hospital was recorded.

6. A review of document titled "Mildred Mitchell-Bateman Hospital Nursing Administration APS Investigation Check-Off List" revealed an allegation of abuse by RN #1 on patient #31 occurred 7/27/19. RN #1 was suspended on that date. A report from the Patient Advocate dated 8/1/19 stated in part: "The allegation is unsubstantiated." RN #1 was returned to duty without a full investigation by the hospital.

7. A review of policy titled "Patient's Rights and Responsibilities," effective date 9/24/19, revealed patients have the right in part: "12. To be free from verbal, mental, physical, and sexual abuse; harassment ..."

C. Based on interviews, clinical record reviews and document reviews it was determined one (1) patient (patient #1) was denied his right to be free from potential abuse on two (2) occasions. The hospital's mandatory reporters failed to file Adult Protective Services (APS) reports within forty-eight (48) hours of the events. This delayed investigation into the events so corrective action could be taken.

Findings include:

1. An interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Director of Human Resources (DHR) and the Assistant Chief Executive Officer (ACEO) on 2/3/20 at 11:30 a.m. During the interview the ACEO revealed RN #1 was suspended as soon as administration received report on 1/14/19 that there was an incident of alleged abuse by RN #1 from 1/9/20.

2. An interview was conducted with the Patient Advocate on 2/4/20 at 11:55 a.m. She revealed she has the authority to investigate any allegations of abuse which occur beyond the case she is investigating. The Patient Advocate acknowledged she received a report from the Behavioral Psychologist when she was interviewed on 1/20/20 that the Behavioral Psychologist told her about an incident of possible abuse which occurred on 1/7/20. The Patient Advocate then told surveyors about the incident which she included in her report dated 2/3/20. This incident was separate from the incident she was investigating from 1/9/20 but involved the same nurse, RN #1. When questioned by the surveyors if she had the authority to start an investigation into the 1/7/20 allegation when she received it, she responded yes. The Patient Advocate stated she feels she should have done this.

3. An interview was conducted with the Chief Executive Officer (CEO) on 2/4/20 at 2:00 p.m. He stated the full written report was not received from the Patient Advocate until 2/3/20. The CEO stated before that date he had no information about the investigation, even from RN #3, who was involved in the investigation. He stated he conducted his own investigation after the advocate's investigation. The CEO stated based on his investigation and in part: "On gut instinct" he decided to terminate RN #1. The termination did not occur until 1/29/19.

4. An interview was conducted with the ADON on 2/5/20 at 10:20 a.m. The ADON revealed she called him and returned him to duty on 1/27/20 after she was called by the DHR and informed the Patient Advocate had advised her the allegation of abuse was unsubstantiated. She revealed patient #1 worked 1/28/20 and 1/29/20. The ADON stated she was instructed by the DHR on 1/29/20 to terminate RN #1, take his badge and keys and tell him he must leave the premises. She did this after RN #1 worked his full shift on 1/29/20. She revealed she asked the DHR why he was terminated and received no answer. She revealed she usually must terminate without knowing the reason and she thinks this is information she needs.

5. A review of document titled "Mildred Mitchell-Bateman Hospital Incident Report" for abuse which allegedly occurred on 1/9/20 showed the hospital did not suspend the accused employee (RN #1) until 1/14/20. The date the APS report was filed was 1/14/20. A review of document (untitled) revealed RN #1 was returned to duty on 1/28/20 and worked two (2) days (1/28/20 and 1/29/20).

6. A review of document titled "Legal Aid of WV" dated 2/3/20 and authored by the Patient Advocate revealed an interview was conducted with the Behavioral Psychologist on 1/21/20. During the interview the Patient Advocate noted the Behavioral Psychologist stated in part: " ...there were times when she thought injections were called far too quickly rather than attempting de-escalation. She confirmed that she was referring specifically to RN #1 with this statement. She described an incident on the unit where RN #1 intervened due to patient #1's behaviors and a code was called and RN #1 stated, "I've got all these people here now and you're getting shots." A review of the conclusion of the report revealed it stated in part: "The allegation is unsubstantiated."

7. A review of policy titled "Patient Rights and Responsibilities," effective date 9/24/19, revealed it states patients have the right in part: "to be free from verbal, mental, physical, and sexual abuse: harassment ..."

C. Based on interviews and document reviews it was determined the hospital failed to appointment a committee to investigate allegations of abuse and neglect. The hospital failed to measure and track the performance of investigations and the conclusions of investigations for one (1) patient (patient #1). This failure prevented investigation into two (2) incidents of alleged abuse to patient #1. This failure places all patients at risk for harm.

Findings include:

1. An interview was conducted with the Chief Executive Officer (CEO) on 02/05/20 at 9:30 a.m. who is a voting member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process, he stated in part: "I think the meeting was the same time we completed policies." He was asked to please find the meeting minutes where the governing body voted on the decision to make a grievance committee and the personnel responsible.

2. An interview was conducted with the Assistant Chief Medical Officer on 02/05/20 at 12:50 p.m. who is a member of the governing body. When asked how often he attends the governing body meetings he stated in part: "I've attended almost all of them since I was a resident here and continued after I began working here." When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that being a part of any meeting but completing our own investigations and the advocate completing theirs is a great idea that will be beneficial to all patients."

3. An interview was conducted with the Director of Quality Assurance/Performance Improvement on 2/5/20 at 1:35 p.m. When asked if there was a committee appointed to investigate grievances and complaints she stated, "There is no grievance committee."

4. An interview was conducted with the Director of Human Resources on 02/05/20 at 3:00 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, not in the three (3) years I have been here."

5. A telephone interview was conducted with the Chief of Staff on 02/05/20 at 4:38 p.m. who is a member of the governing body. When asked if the governing body had a governing meeting that declared in writing a grievance committee with personnel responsible to complete the grievance process he stated in part: "No, I don't remember that occurring." When asked if he attends all meetings he stated in part: "I attend most but if I can't, my assistant attends and fills me in on what happens."

6. An interview was conducted with the CEO on 02/06/20 at 11:30 a.m. prior to exit. When asked if he had found the meeting minutes with the vote on a grievance committee he stated in part: "No, there wasn't any."

7. Review of the governing body meeting minutes from January 2019 through present and staff interviews revealed the governing body does not complete grievances and have not named a grievance committee. Review of five (5) adult protective orders revealed the facility does not complete their own investigations and relies on the Legal Aide Patient Advocate to complete an investigation.

8. Review of the governing body meeting minutes from January 2019 through present revealed the governing body does not complete investigations of grievances nor is there a grievance committee that has been approved in writing with members of the committee named

9. A document titled "Legal Aid of West Virginia" was received by the facility on 2/3/20 (the date of the State surveyors' entrance). The document was written by the advocate who investigated an allegation of abuse which occurred on 1/9/19. The allegation was against RN #1 to patient #1. A review of the document revealed the Behavioral Psychologist was interviewed by the advocate on 1/21/20. During the interview the Behavioral Psychologist told the advocate she overheard RN #1 threaten patient #1 after a code was called saying in part: "I've got all these people here now and you're getting shots." The Patient Advocate did not investigate this allegation of abuse. She wrote in the conclusion to her investigation the allegation of abuse was in part: "unable to be substantiated."

C. Based on interviews, documents and policy reviews it was determined the hospital failed to ensure Registered Nurse (RN) #1 was suspended from duty providing care after staff noted alleged abuse. The hospital failed to keep RN #1 on suspension until it completed a full investigation. This failure places all patients at risk for harm.

Findings include:

1. An interview was conducted with the Director of Nursing (DON), the Assistant Director of Nursing (ADON), the Director of Human Resources (DHR) and the Assistant Chief Executive Officer (ACEO) on 2/3/20 at 11:30 a.m. During the interview the ACEO revealed RN #1 was suspended as soon as administration received report on 1/14/19 that there was an incident of alleged abuse by RN #1 from 1/9/20.

2. An interview was conducted with the Chief Executive Officer (CEO) on 2/4/20 at 2:00 p.m. He stated the full written report was not received from the Patient Advocate until 2/3/20. The CEO stated before that date he had no information about the investigation, even from RN #3, who was involved in the investigation. He stated he conducted his own investigation after the advocate's investigation. The CEO stated based on his investigation and in part: "On gut instinct" he decided to terminate RN #1. The termination did not occur until 1/29/19.

3. An interview was conducted with the ADON on 2/5/20 at 10:20 a.m. The ADON revealed she called him and returned him to duty on 1/27/20 after she was called by the DHR and informed the Patient Advocate had advised her the allegation of abuse was unsubstantiated. She revealed patient #1 worked 1/28/20 and 1/29/20. The ADON stated she was instructed by the DHR on 1/29/20 to terminate RN #1, take his badge and keys and tell him he must leave the premises. She did this after RN #1 worked his full shift on 1/29/20. She revealed she asked the DHR why he was terminated and received no answer. She revealed she usually must terminate without knowing the reason and she thinks this is information she needs.

4. A review of document titled "Mildred Mitchell-Bateman Hospital Incident Report" for abuse which allegedly occurred on 1/9/20 showed the hospital did not suspend the accused employee (RN #1) until 1/14/20. The date the APS report was filed was 1/14/20. A review of document (untitled) revealed RN #1 was returned to duty on 1/28/20 and worked two (2) days (1/28/20 and 1/29/20). No investigation of the incident by the hospital was recorded.

5. A review of document titled "Mildred Mitchell-Bateman Hospital Nursing Administration APS Investigation Check-Off List" revealed an allegation of abuse by RN #1 on patient #31 occurred 7/27/19. RN #1 was suspended on that date. A report from the Patient Advocate dated 8/1/19 stated in part: "The allegation is unsubstantiated." RN #1 was returned to duty without a full investigation by the hospital.

6. A review of policy titled "Patient's Rights and Responsibilities," effective date 9/24/19, revealed patients have the right in part: "12. To be free from verbal, mental, physical, and sexual abuse; harassment ..."

C. Based on document review and staff interviews it was determined the Director of Health Information failed to maintain an accurate medical record in seven (7) of seven (7) medical records altered without the author's knowledge. This failure has medical records without accurate information that can alter a patient's care and treatment.

1. A review of documents titled "Entered in Error" revealed seven (7) nurse's charting was removed from the medical record at the request of the Nurse Manager but without permission from the author of the note.

2. Review of medical records charting guidelines without a date of review or revision states in part: "Any errors in the notes tab of the electronic medical record shall be retracted by the Director Health Information Management or designated individual. The author must complete an "entered in error" report...to request the note be removed."

3. An interview was conducted with the Director of Health Information on 02/04/20 at 10:25 a.m. When shown the guidelines and the nursing notes that had been removed without the author's permission and asked why this occurs she stated in part: "That's how we've always done it. I didn't know it was wrong but I see now why it is."

4. An interview was conducted on 02/05/20 at 10:00 a.m. with the Director of Quality in the presence of the Assistant Chief Operating Officer. When the altered medical records were shown to them they both concurred the medical record should not be altered or deleted without permission of the author of the note. The Nurse Manager should not make the request and it be granted.

C. Based on document review and staff interviews it was determined the Director of Health Information failed to maintain an accurate medical record in seven (7) of seven (7) medical records altered without the author's knowledge. This failure has medical records without accurate information that can alter a patient's care and treatment.

1. A review of documents titled "Entered in Error" revealed seven (7) nurse's charting was removed from the medical record at the request of the Nurse Manager but without permission from the author of the note.

2. Review of medical records charting guidelines without a date of review or revision states in part: "Any errors in the notes tab of the electronic medical record shall be retracted by the Director Health Information Management or designated individual. The author must complete an "entered in error" report...to request the note be removed."

3. An interview was conducted with the Director of Health Information on 02/04/20 at 10:25 a.m. When shown the guidelines and the nursing notes that had been removed without the author's permission and asked why this occurs she stated in part: "That's how we've always done it. I didn't know it was wrong but I see now why it is."

4. An interview was conducted on 02/05/20 at 10:00 a.m. with the Director of Quality in the presence of the Assistant Chief Operating Officer. When the altered medical records were shown to them they both concurred the medical record should not be altered or deleted without permission of the author of the note. The Nurse Manager should not make the request and it be granted.

A. Based on observation, record review and staff interviews the facility failed to maintain and provide a sanitary environment in accordance with the infection prevention and control program which must include appropriate monitoring of housekeeping and maintenance activities. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was 109.

Findings included:

1. Observation on 12/16/19 at approximately 11:44 a.m. revealed the electric steam kettle in the kitchen had a leaking basin near the drain area.

2. Observation on 12/16/19 at approximately 11:46 a.m. revealed the middle steam kettle in the kitchen had a damaged drain pan which had fluid/material pooling on the right-hand side of the pan away from the pan drain.

3. Observation on 12/16/19 at approximately 11:49 a.m. revealed the wall behind the middle steam kettle in the kitchen had torn and missing wall covering and exposed plaster behind the wall covering.

4. Observation on 12/16/19 at approximately 11:55 a.m. revealed loose/hanging vinyl covering of the ceiling tile in the food preparation area of the kitchen near the coffee pot area.

5. Observation on 12/16/19 at approximately 12:00 p.m. revealed the pedestal fan in the food preparation area of the kitchen that appeared covered with dust/debris.

6. Observation on 12/16/19 at approximately 12:03 p.m. revealed leaking pipes under the vegetable cutter and preparation sinks in the food preparation area of the kitchen.

7. Observation on 12/16/19 at approximately 12:04 p.m. revealed the meat cooler in the kitchen that appeared to have meat/food droppings on the floor.

8. Observation on 12/16/19 at approximately 12:05 p.m. revealed the food racks in the meat cooler in the kitchen that appeared to be rusty.

9. Observation on 12/16/19 at approximately 12:06 p.m. revealed the door handle on the inside of the meat cooler in the kitchen that appeared to be rusty.

10. Observation on 12/16/19 at approximately 12:07 p.m. revealed the base plates near the wheels on the toaster cart in the kitchen that appeared covered with dust/debris.

11. Observation on 12/16/19 at approximately 12:09 p.m. revealed the ceiling air vents throughout the kitchen that appeared covered with dust/debris.

12. Observation on 12/16/19 at approximately 12:15 p.m. revealed missing and broken floor tile in the food serving area of the kitchen.

13. Observation on 12/16/19 at approximately 12:17 p.m. revealed the preparation table near the hand sink in the food serving area that appeared stained with floor wax/stripper.

14. Observation on 12/16/19 at approximately 12:20 p.m. revealed the ceiling grid in the dish room of the kitchen that appeared rusty.

15. Observation on 12/16/19 at approximately 12:22 p.m. revealed missing and unsealed floor tile in the dish room of the kitchen.

16. Observation on 12/16/19 at approximately 12:23 p.m. revealed missing and broken cove base in the dish room of the kitchen.

17. Observation on 12/16/19 at approximately 12:24 p.m. revealed deteriorating wall plaster near the missing and broken cove base in the dish room of the kitchen.

18. Observation on 12/16/19 at approximately 12:26 p.m. revealed an unused ceiling mounted air conditioning unit in the dish room of the kitchen that has not been cleaned and is currently covered up with plastic sheeting until the unit is removed.

19. Record review on 12/17/19 at approximately 1:37 p.m. revealed cleaning schedules for the kitchen did not indicate how often specific areas of the kitchen were cleaned and which staff were responsible for cleaning the specific areas of the kitchen.

20. An interview conducted on 12/17/19 at approximately 1:39 p.m. with the Infection Control Nurse verified these findings. The findings were also acknowledged by the Chief Executive Officer on 12/17/19 at approximately 4:30 p.m.

A. Based on record review and staff interviews the Infection Control (IC) program failed to ensure maintenance of a sanitary physical environment in accordance with the infection control officer's responsibility for measures to identify, investigate, report, prevent and control infections and communicable diseases. This deficient practice could affect all patients, staff and visitors in the areas referenced. The facility's census was 109.

Findings included:

1. Record review on 12/17/19 at approximately 1:45 p.m. revealed housekeeping and equipment work orders for the Dietary Department which were submitted as a result of deficiencies identified during the 8/5/19 Infection Control rounds and 8/15/19 County Health Department inspection which had not been completed as of the date of this complaint survey.

2. An interview conducted on 12/17/19 at approximately 1:47 p.m. with the Infection Control Nurse verified this finding. The finding was also acknowledged by the Chief Executive Officer on 12/17/19 at approximately 4:30 p.m.