The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

HIGHLAND HOSPITAL 300 56TH ST SE CHARLESTON, WV 25304 Dec. 3, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
Based on document review, record review and staff interview it was determined the facility failed to ensure staff followed hospital policy relative to conducting a face-to-face evaluation of a patient in restraint/seclusion within one (1) hour after the initiation of the intervention. This deficient practice was found in two (2) of six (6) patients reviewed who were placed in restraint/seclusion (patients #4 and #6). This failure has the potential to negatively impact the safety and quality of care received by all patients served by the hospital who are placed in restraint/seclusion.

Findings include:

1. Review of the hospital policy entitled, "Seclusion and Restraint", last revised 3/15, states in part: "...the physician or RN must make a face-to-face evaluation of the patient within 1 hour of initiation of the order and document the evaluation."

2. Review of the medical record for patient #4 revealed no evidence of a face-to-face evaluation by the physician or Registered Nurse (RN) within one (1) hour of order initiation for the following dates: 9/24, 9/25, 9/30, 10/2, 10/8, 10/13, 10/14, 10/19, 10/20, 10/21, 10/23, 10/27, 10/28 and 11/3/15.

3. Review of the medical record for patient #6 revealed no evidence of a face-to-face evaluation by the physician or RN within one (1) hour of order initiation for the following dates: 9/22, 9/25, 10/2, 10/8, 10/19, 10/20 and 10/21/15.

4. The above records were reviewed with the Program Manager of the Tween Unit on 12/3/15 at 10:15 a.m. and she agreed with the findings.