HospitalInspections.org

Based on clinical record review, document review and staff interviews it was determined the facility failed to protect patient's rights by failing to provide care in a safe setting, to protect the patient from all types of abuse and follow facility policies. This failure was identified in one (1) out of thirty (30) patient record reviews (patient #2). These findings have the potential to place all patients at risk for abuse and injury. (See tags A 118, A 144 and A 145).

A. Noncompliance: The facility failed to ensure patient #2 received care in a safe setting and was free from all forms of abuse. The facility failed to ensure Nurse Manager #1 document an assessment of the patient and immediately notify the physician of the patient's injuries which required the patient to go to the Emergency Department (ED). The facility failed to ensure all staff follow facility policies to report patient incidents and to report abuse to the Child Protective Services Mandatory report within twenty-four (24) hours in accordance with applicable West Virginia (WV) state law. This failure was identified in one (1) out of thirty (30) patient record reviews.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Patient #2 was injured in an undocumented physical altercation with another patient. The Nurse Manager failed to provide care in a safe setting, failed to document an assessment of the patient and notify the physician of a change in patient condition.

C. Need for Immediate action: The facility needs to correct their processes to ensure staff provide and document immediate care of the patient and the physician is notified in a timely manner of any changes of patient condition or injury.

D. An immediate plan of correction was received and sent to the State agency Program Director. It was accepted and the facility abated the Immediate Jeopardy (IJ) on 04/13/21 at 5:08 p.m.

Based on clinical record review, document review and interviews it was determined the facility failed to ensure Nurse Manager (NM) #1 follow the facility grievance/complaint policy in the abuse of patient #2. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director, or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse, or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the Director of Nursing (DON) notified the ambulance." When asked if an incident report was completed, she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."

A. Based on clinical record review, document review and staff interview it was determined the facility failed to provide patient care in a safe setting for patient #2 and notify the physician immediately of abuse and a change in patient condition. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director, or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse, or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the Director of Nursing (DON) notified the ambulance." When asked if an incident report was completed, she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."


B. Based on clinical record review, document review and staff interview it was determined the facility failed to provide patient care in a safe setting for patient #2 by failing to assess and document care provided to patient #2. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director, or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse, or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the Director of Nursing (DON) notified the ambulance." When asked if an incident report was completed, she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."


C. Based on clinical record review, document review and interviews it was determined the facility failed to ensure Nurse Manager #1 follow the facility grievance/complaint policy in the abuse of patient #2. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper, and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director, or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse, or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/workday. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ...? All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at any time the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the Director of Nursing (DON) notified the ambulance." When asked if an incident report was completed, she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."

Based on clinical record review, document review and staff interviews it was determined the facility failed to ensure patient #2 was free from all forms of abuse or harassment. The facility failed to follow policies and procedures and complete and submit a Child Protective Services Mandatory report in accordance with applicable West Virginia State law and a facility incident report. This failure was identified in one (1) out of thirty (30) patient record reviews.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the Director of Nursing (DON) notified the ambulance." When asked if an incident report was completed she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."

Based on clinical record review, document review and staff interviews it was revealed the facility failed to ensure nursing staff supervise and evaluate nursing care for patient #2, failed to assess and document patient care following changes in patient condition, failed to notify the provider and failed to follow facility policies and procedures for reporting abuse, grievances and incidents. This failure was identified in one (1) out of thirty (30) patient record reviews. These findings have the potential for all patients to be at risk for abuse and injury. (See tags A-0395 and A-0398).

A. Noncompliance: The Interim Director of Nursing failed to ensure all nursing staff supervise and evaluate patient care, assess and document patient care, failed to notify the provider immediately of patient #2's abuse and follow facility policies for reporting a patient grievance, an incident report and a Child Protective Services Mandatory report in accordance with applicable West Virginia State law. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure had the potential to place all patients at risk for abuse and injury.

B. Serious Adverse Outcome or Likely Serious Adverse Outcome: Facility staff not notifying the provider immediately or as soon as possible can place the patient at risk for a physical or mental adverse event.

C. Need for Immediate action: The facility needs to correct their processes to ensure providers are immediately notified as soon as possible of any injuries or events that can cause changes in patient condition.

D. An immediate plan of correction was received and sent to the State agency Program Director. It was accepted and the facility abated the IJ on 04/13/21 at 5:08 p.m.

A. Based on clinical record review, document review and interview the Interim Director of Nursing (DON) failed to ensure all nursing staff supervise and evaluate the nursing care for patient #2 by ensuring the provider was notified immediately by the Nursing Department when the patient was physically abused. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the DON notified the ambulance." When asked if an incident report was completed she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."


B. Based on clinical record review, document review and interview the Interim DON failed to ensure all nursing staff supervise and evaluate the nursing care for patient #2 by ensuring nursing staff assessed and documented care provided to patient #2 when she was abused. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the DON notified the ambulance." When asked if an incident report was completed she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."

A. Based on observation, document review and interview the Interim Director of Nursing (DON) failed to ensure facility nursing staff follow the facility grievance/complaint policies and procedures and incident reporting procedure in the physical abuse of patient #2 requiring the patient to need Emergency Department (ED) evaluation. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the DON notified the ambulance." When asked if an incident report was completed she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."


B. Based on observation, document review and interview the Interim DON failed to ensure facility nursing staff follow the facility 'Nursing Assessment/Reassessment' policy and notify the physician and assess and document care provided to patient #2 when she was abused. This failure was identified in one (1) out of thirty (30) patient record reviews. This failure to provide care in a safe setting has the potential for all patients to be at risk for abuse and injury.

Findings include:

1. A review of patient #2's clinical record was conducted on 04/12/21 and revealed a 'Nursing Shift Note' by Registered Nurse (RN) #5 dated 04/08/21 at 12:41 p.m. that stated in part: "Patient #2 is calm and cooperative overall; denies ideations or hallucinations; attending scheduled groups and compliant with treatment; safety maintained." The next 'Nursing Shift Note' written by RN #6 dated 04/09/21 at 2:13 a.m. stated in part: "Patient #2 remains at the hospital for evaluation. Will await return from Emergency Department." The next 'Nursing Shift Note' written by RN #7 dated 04/09/21 at 3:09 a.m. states in part: "Patient #2 returned from Women's and Children's Emergency Department ... at approximately 2:30 a.m. The report from ER (Emergency Room) evaluation was there had been no significant physical damage that patient #2 had sustained from a fight in which she was involved, save some mild contusions ...." Further review of the clinical record revealed there was not any documentation of the patient's incident, physical injuries, outcome, notification of the physician, guardian or orders received for patient care at the time the incident occurred.

2. A review of facility policy, 'Grievance and Complaint Process,' revised 07/24/19, states in part: "It is the policy of Highland Hospital to provide patients, their families, and staff with a vehicle for communicating grievances, concerns or complaints regarding services and patient care at Highland Hospital. There is an obligation, legal and moral, to report suspected abuse, neglect or mistreatment and such concerns shall be addressed within forty-eight (48) hours. ... All verbal or written complaints regarding abuse, neglect or patient harm or hospital compliance with CoP's (Conditions of Participation) are grievances. ... Objective: ... ensures all employees know how to process grievances and complaints: and to ensure timely, proper and efficient documentation of grievances. ..."

3. A review of facility policy, 'Allegations of Patient Abuse,' revised 12/04/19, states in part: "Any allegations, by patient or others, of patient abuse by hospital staff, physicians, allied health professionals or other patients will be viewed with the utmost seriousness. All allegations will be fully investigated. ... 2. The individual receiving the allegation will immediately notify the Program Manager or Nurse Supervisor of the allegation, complete an incident report regarding the allegation as soon as possible and forward the report to the Nurse Supervisor. ... 3. When physical abuse is alleged, the patient must be assessed by the attending, on call physician, Medical Director or designee (which may be a Registered Nurse), within twelve (12) hours following receipt of the allegation. The Program Manager or Nursing Supervisor will be responsible for notifying the attending physician of the allegation. ... 7. Any person who has reasonable cause to suspect that a child is neglected or abused, or observes the child being subjected to conditions that are likely to result in abuse or neglect will file immediately, not more than twenty-four (24) hours after evidence of suspected abuse or neglect, the circumstances and cause a report to be made to the Department of Health and Human Resources. In any case where the reporter believes that the child suffered serious physical abuse, sexual abuse or sexual assault the reporter shall also immediately report or cause a report to be made to the State Police and any law enforcement agency having jurisdiction to investigate the complaint. ..."

4. A review of facility policy, 'Abuse Reporting - Adult/Child and Documentation,' revised 04/2018, states in part: "Suspected incidents of adult or child abuse, neglect, or emergency situations will be reported as mandated under West Virginia Adult Protected Services Law, Chapter 9, Article 6 and West Virginia Child Protective Law, Chapter 49 of the State Code. A Child Protective Services/Adult Protective Services Form will be completed and sent to DHHR (Department of Health and Human Resources) following any report of suspected and/or neglect of patients. ... Identification: Abuse can be identified by any staff member. ... Identification of abuse can occur in several ways: A. The patient reports he or she is being abused, neglected, or is in an emergency situation. ... Reporting: 1. The staff member will notify the Therapy Services Director, Program Manager, or Nurse Supervisor. 2. The staff member receiving the information regarding any case of suspected or reported abuse or neglect, will report this information to Adult or Child Protective Services with the assistance of the Therapy Services Director, Program Manager, or Nurse Supervisor. ... 4. The staff member will put the original in the discharge section of the chart. 5. The Director of Therapy Services, Program Manager, or Nurse Supervisor will document in the discharge planning section of the chart in a "Special Entry Note" ...."

5. A review of facility policy, 'Incident Reporting and Severity Classification - Acute,' approval 02/2020, states in part: "Any facility staff member who witnesses, discovers or has direct knowledge of an incident should complete an Incident Report as soon as practical after the incident is witnessed or discovered and/or before the end of the shift/work day. An incident report should be filed for any incident including, but not limited to: ... An unusual event that occurs which does or may result in personal and/or bodily injury. ... Observed or alleged physical abuse of patient. ... Patient/visitor falls. ... Information to be entered on the Incident Report includes: ... Who was notified of the event ... All incidents involving patients should be charted in the patient's treatment record. ...

6. A review of facility policy, 'Nursing Assessment/Reassessment,' revised 02/2017, states in part: "The reassessment of the patient is ongoing. The patients will be reassessed every eight (8) hours. Any changes in the patient's physical or mental status that warrants physician notification will be reported to the Unit Nurse. It will be the responsibility of the Unit Nurse or designee to call the physician at anytime the assessment/reassessment indicates a need to communicate with the physician."

7. An interview was conducted on 04/13/21 at approximately 2:10 p.m. with the Director of Risk and Quality. When asked if an incident report for patient #2 was completed he stated in part, "I thought it was in the Nurse Manager's (NM) office, but there was not any incident report done. No investigation was done."

8. An interview was conducted on 04/13/21 at approximately 2:25 p.m. with NM #1. When asked about the incident with patient #2 she stated in part, "I was on the phone and heard her with another patient having a conversation. ... I heard them getting louder. I was on the phone with another nurse ... I put them on hold and did an all call. Then another patient from the unit hit patient #2 in the face. Then the girl who was yelling attacked her hitting her. ... Patient #2 was on the ground at some point. I had to unlock myself out of the nurse's office and got the girl hitting patient #2 in a hold ... It happened at about 7:28 p.m. ...." When notified no one had documented anything in the patient's chart, documented notification of the physician, guardian or documented an assessment of the patient, she stated in part, "We did notify the physician, RN #4 notified the mom ... the DON notified the ambulance." When asked if an incident report was completed she stated in part, "I don't know if an incident report was done. I don't remember doing one." When notified there was no documentation in the chart about the incident and care of the patient, she concurred.

9. An interview was conducted on 04/13/21 at approximately 3:15 p.m. with the Interim DON. When notified there was not any documentation in patient #2's chart of an assessment, notifying the physician and notifying the guardian she stated in part, "I took the call with NM #1 with the physician and asked her to put in the order. I didn't follow up to check it was done. I requested NM #1 to put in an incident report. I didn't follow up with her that it was done. ..." When notified nothing was documented she stated in part, "I should have followed up to make sure it was documented."