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 July 12, 2017
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on policy review, medical record review and staff interview it was determined the facility failed to ensure verbal/telephone orders for restraint/seclusion were authenticated by the physician in four (4) of seven (7) patients who were ordered restraints/seclusion (patients #1, 2, 5 and 11). This failure has the potential to negatively impact patient safety for all patients who are placed in restraint/seclusion at the facility.

Findings include:

1. Review of the hospital policy entitled "Seclusion and Restraint", last revised 4/25/17, revealed it states, in part: "The physician must also "authenticate" a telephone restraint/seclusion order by signing, dating and timing the order."

2. A review of the medical record for patient #1 revealed orders for restraint/seclusion were not authenticated by the physician for 1/7 and 1/10/17.

3. A review of the medical record for patient #2 revealed orders for restraint/seclusion were not authenticated by the physician for 4/11, 4/29, 5/10 and 5/22/17.

4. A review of the medical record for patient #5 revealed orders for restraint/seclusion were not authenticated by the physician for 2/4, 2/5, 2/18, 2/24 and 3/20/17.

5. A review of the medical record for patient #11 revealed orders for restraint/seclusion were not authenticated by the physician for 1/7/17.

6. The above findings were reviewed with the Director of Nursing during an interview on 7/11/17 at 3:08 p.m. and she agreed with the findings.