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 May 24, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on document review and staff interview it was determined the hospital failed to ensure patients received care in a safe setting. This failure impacted three (3) of ten (10) patients reviewed and has the potential to adversely impact the condition of all patients (patients # 3, 4 and 5).

Findings include:

1. Interview was conducted with the Director of Risk Management at 11:00 a.m. on 5/22/17. She stated staff are prohibited from contacting patients or former patients on social media. She stated hospital policy related to prohibiting relationships with patients is covered in staff orientation.

2. The policy "Employee-Patient Relationships," last revised 6/15, was provided for review. The policy states, in part: "Staff are to be aware of patient vulnerability and under no circumstances should engage in behavior in their relations with patients that are exploitive, abusive, neglectful, or harmful in any manner...The Hospital recognizes that the nature of a patient-staff provider relationship places the patient at an inherent disadvantage. Thus, an intimate, romantic or sexual relationship is prohibited between a patient and any staff who becomes acquainted with that patient and any staff who becomes acquainted with that patient in the context of a patient service provider relationship. Accordingly, staff members may not engage at any time in the Hospital or in an outpatient setting, an intimate, romantic or sexual relationship with a patient. Staff members are responsible for ensuring that their behavior does not give the appearance to the patient or to others that an intimate, romantic or sexual relationship exists."

3. Review of the Adolescent Unit Discharges for March - May 2017, current census and a public social media site (Facebook) revealed there were three (3) patients (patients #3, 4 and 5) who were currently listed as friends on the Facebook account of Behavioral Health Technician #4, who works on the Adolescent Unit.

4. Anonymous interviews with staff who work on the Adolescent Unit, conducted during the course of the survey, revealed porn had been found on a computer on the Adolescent Unit. These interviews revealed staff had suspicions about which staff member was watching the porn. One (1) staff member described a co-worker who frequently sat at the computer behind the nursing station for prolonged periods watching "something" that was not job related.

5. In the early afternoon of 5/23/17 the above information was discussed with the Director of Quality and Risk. She stated the Information Technology Director found evidence on hospital servers that pornographic materials were viewed but it could not be proven who viewed the materials. A request was made for the staff interviews conducted related to this allegation. The Director stated no staff interviews were available and confirmed the hospital was not currently monitoring staff performance related to potential viewing of porn on computers on the Adolescent Unit.

6. At 8:33 a.m. on 5/24/17 the Adolescent Unit Program Manager was interviewed. She stated she was not involved in the porn investigation and had not conducted staff interviews regarding the incident.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on document review and staff interview it was determined the hospital failed to ensure the performance improvement program oversaw the investigation of a report of high risk behavior and failed to maintain a record of interventions taken to investigate and address the incident and steps taken to reduce the likelihood of a recurrence. This failure involved one (1) of one (1) staff members (Behavioral Health Technician (BHT) #3) identified by surveyors as having viewed pornographic materials while on duty. This failure has the potential to adversely impact the safety of all patients.

Findings include:

1. During the course of anonymous staff interviews it was reported by a staff member that BHT #3 had been found to have viewed pornographic materials on the hospital computer while on duty on the Adolescent Unit. The Clinical Director was named as a witness to the discovery that porn was found on the Unit computer.

2. The above finding was discussed with the Clinical Director at 11:18 a.m. on 5/23/17. He confirmed he was on a unit when a nurse informed him that pornographic material had been "pulled up" on the Unit computer. He stated he notified the Information Technology (IT) Department and Security of the incident.

3. In the early afternoon of 5/23/17 the above information was discussed with the Director of Quality and Risk. She stated the IT Director found evidence on hospital servers that pornographic materials were viewed but it could not be proven who viewed the materials.

4. At 8:00 a.m. on 5/24/17 the Director of Quality was asked if an incident form was completed regarding the "porn" incident and if staff on the Unit were interviewed. She stated the former Human Resource Director had conducted the investigation.

5. At 8:33 a.m. on 5/24/17 the Adolescent Unit Program Manager was interviewed. She stated she was not involved in the porn investigation and had not conducted staff interviews regarding the incident.

6. At 9:00 a.m. on 5/24/17 the Director of Quality confirmed no incident form had been completed and the Quality/Performance Improvement department did not oversee the investigation. She stated the department hadn't maintained a file and confirmed the department didn't report or follow-up on the findings or any steps necessary to track and monitor staff performance and to reduce the likelihood of recurrence.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of documents and public social media sites and staff interview it was determined the registered nurse failed to supervise the care provided by one (1) of one (1) Behavioral Health Technicians (BHT) who was found to have initiated an inappropriate employee/patient relationship. This failure creates the potential for the care and condition of all patients to be adversely impacted.

Findings include:

1. Interview was conducted with the Director of Risk Management at 11:00 a.m. on 5/22/17. She stated staff are prohibited from contacting patients or former patients on social media. She stated hospital policy related to prohibiting relationships with patients is covered in staff orientation.

2. The policy "Employee-Patient Relationships," last revised 6/15, was provided for review. The policy states, in part: "Staff are to be aware of patient vulnerability and under no circumstances should engage in behavior in their relations with patients that are exploitive, abusive, neglectful, or harmful in any manner...The Hospital recognizes that the nature of a patient-staff provider relationship places the patient at an inherent disadvantage. Thus, an intimate, romantic or sexual relationship is prohibited between a patient and any staff who becomes acquainted with that patient and any staff who becomes acquainted with that patient in the context of a patient service provider relationship. Accordingly, staff members may not engage at any time in the Hospital or in an outpatient setting, an intimate, romantic or sexual relationship with a patient. Staff members are responsible for ensuring that their behavior does not give the appearance to the patient or to others that an intimate, romantic or sexual relationship exists."

3. The job description for Behavioral Health Technician (BHT), updated 11/24/03, was provided for review. The job description states, in part: "The Behavioral Health Technician works under the direct supervision of a licensed nurse...Essential Functions...Follows Highland Hospital policies and procedures including personnel, nursing, and administrative policies. Maintains patient confidentiality at all times."

4. Review of the Adolescent Unit Discharges for March - May 2017, current census and a public social media site (Facebook) revealed there were three (3) patients (patient #3, 4 and 5) who were currently listed as friends on the Facebook account of BHT #4.

5. Interview was conducted with BHT #4 at 3:00 p.m. on 5/23/17. He was told surveyors were investigating inappropriate behavior of male staff including allegations of staff sending Facebook friend requests to patients. He was asked about hospital policy/expectation and he stated that behavior was prohibited. The surveyor told the BHT that three (3) former patients had been identified as his current Facebook friends. The BHT did not deny this and first stated that he accepts everyone; then stated he accepts only those he knows personally. When asked why he befriended patients he stated he hadn't really thought about it. At that point in the interview the BHT offered to remove the patients from his friend list "that he could remember". He was told to discuss this with hospital administration as he had not followed policy.