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.

WILLIAM R SHARPE, JR HOSPITAL 936 SHARPE HOSPITAL ROAD WESTON, WV April 25, 2012
VIOLATION: CHIEF EXECUTIVE OFFICER Tag No: A0057
Based on document review and staff interview it was determined the Chief Executive Officer (CEO) or designee failed to ensure that hospital staff perform an investigation that is completed within fourteen (14) days from any allegations of abuse and to make a determination if the findings are substantiated or not as prescribed by hospital policy. This deficient practice affected one (1) of nineteen (19) reports of patient sexual assaults by hospital personnel (patient #1). Failure to fully investigate allegations of sexual assault and take any corrective actions can result in ongoing abuse of patients.

Findings include:

1. Review of hospital policy #45.031-A (Effective July 2008) revealed in part the following: "The CEO/designee will assign hospital staff to investigate all allegations of abuse and staff may join the patient advocate to conduct the investigation jointly or separately. Hospital staff will complete the abuse investigation within fourteen (14) days of the allegation. The CEO/designee will authorize changes in this process and ensure the investigation proceeds promptly and thoroughly. After completion of the investigation the CEO/designee will determine if it was substantiated and take appropriate actions".

2. Adult Protective Services (APS) reports were reviewed from December 2010 to present that involved allegations of sexual abuse by a hospital employee. A total of nineteen (19) APS reports were found to involve allegations of sexual abuse by hospital employees. All of these cases had been reviewed and completed with a determination by (CEO)/designee whether they were substantiated or unsubstantiated. One (1) recent report was filed on 4/20/12 which is still under investigation. Another report involving patient #1 was filed on 7/18/11 (over nine (9) months ago).

3. The CEO was interviewed on 4/23/12 at 1045 hours concerning why at the present time there is not a completed investigation into the allegations of the sexual assault of patient #1 by a hospital employee. He stated they had been informed by the patient advocate, who is not a hospital employee, the state police were performing a criminal investigation into these allegations and requested them not do anything that might jeopardize their investigation. When questioned as to if he or anyone from administration had spoken directly with the state police he stated "no" however he had attempted to call the investigating state trooper a few weeks ago and left several messages but has never gotten any response from him. He asserted that at the present time he has not received any release from the state police to perform an investigation. When asked if at the present time whether they had conducted a comprehensive hospital investigation into this situation or discussed it with the Quality Assurance Committee he stated "no we have not."
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 that all patients are cared for in a safe environment and free from abuse or sexual assault and failed to investigate and take corrective action where appropriate. This deficient practice was found in one (1) of nineteen (19) adult protective services reports involving allegations of patient sexual assault by a hospital employee (patient #1). Failure to fully investigate allegations of sexual assault and take any corrective actions can result in ongoing abuse of patients.

Findings include:

1. Review of hospital policy #45.031-A (Effective July 2008) revealed in part the following: "The Chief Executive Officer (CEO)/designee will assign hospital staff to investigate all allegations of abuse and staff may join the patient advocate to conduct the investigation jointly or separately. Hospital staff will complete the abuse investigation within fourteen (14) days of the allegation. The CEO/designee will authorize changes in this process and ensure the investigation proceeds promptly and thoroughly. After completion of the investigation the CEO/designee will determine if it was substantiated and take appropriate actions".

2. Adult Protective Services (APS) reports were reviewed from December 2010 to present that involved allegations of sexual abuse by hospital employees. A total of nineteen (19) APS reports were found involving allegations of sexual abuse by hospital employees. All cases had been completed with a determination by the CEO/designee whether or not they were substantiated or unsubstantiated; one (1) case (filed on 4/20/12) is still under investigation. The report involving patient #1 was filed on 7/18/11.

3. A request was made on 4/23/12 at 0900 hours to review the hospital's investigation, which includes their findings with corrective actions for the alleged sexual assault of patient #1 by a hospital employee.

At 4/23/12 at 0900 hours the Chief Nurse Executive (CNE) and the Chief Compliance Officer (CCO) both stated the hospital had not done an investigation into the allegations due to a request by the state police to "keep it confidential." They both asserted that due to the fact the patient had filed the assault charges after her discharge from the hospital, they had only performed document reviews. When questioned if they had interviewed any hospital employees relative to any allegations of abuse by hospital personnel towards any patients they both replied "no." When asked if any additional measures had been taken to increase supervision, staffing or the frequency of patient checks in the unit where the patient had been allegedly assaulted they both replied "no."
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on document review and staff interview it was determined the hospital failed to ensure that all patients are free from abuse and that all allegations of sexual assault are investigated with analysis of the findings and corrective action taken if indicated as required by hospital policy. This deficient practice was found in one (1) of nineteen (19) adult protective services reports involving allegations of patient sexual assault by a hospital employee (patient #1). Failure to fully investigate allegations of sexual assault and take any corrective actions can result in ongoing abuse of patients.

Findings include:

1. Review of hospital policy #45.031-A (Effective July 2008) revealed in part the following: "The Chief Executive Officer (CEO)/designee will assign hospital staff to investigate all allegations of abuse and staff may join the patient advocate to conduct the investigation jointly or separately. Hospital staff will complete the abuse investigation within fourteen (14) days of the allegation. The CEO/designee will authorize changes in this process and ensure the investigation proceeds promptly and thoroughly. After completion of the investigation the CEO/designee will determine if it was substantiated and take appropriate actions."

2. Adult Protective Service (APS) reports were reviewed from December 2010 to present that involved allegations of sexual abuse by hospital employees. A total of nineteen (19) APS reports were found involving allegations of sexual abuse by hospital employees. All cases had been completed with a determination by CEO/designee if it was substantiated or not except for a recent report that was filed on 4/20/12, which is still under investigation, and the report involving patient #1 which was filed on 7/18/11.

3. The patient Advocate and hospital investigator had closed their portion of the APS report involving patient #1 on 3/1/12 with conclusions it was substantiated. These conclusions were based on state police information and review of the patient's medical record. There were no reviews of other patient records, who was present on the unit or interviews of hospital employees or patients to discover if any additional patients or hospital employees were involved.

4. The above was reviewed with the Assistant CEO and the Chief Compliance Officer (CCO) on 4/24/12 at 1030 hours and they agreed all of the APS allegations of sexual abuse had been thoroughly investigated except for a very recent report (4/20/12) that is still under investigation and the APS report involving patient #1 which was filed 7/18/11.

They both said they had not completed an investigation due to reports by the patient advocate who told them the state police was performing a criminal investigation and they were to maintain strict confidentiality.

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VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review and staff interview it was determined that the hospitals Quality Assurance program failed to ensure that all hospital operations and care processes are thoroughly reviewed and discussed with actions taken if indicated to ensure that all patients are maintained free from sexual abuse or assault by hospital employees. This deficient practice was identified in one (1) of nineteen (19) reports of patient sexual assault by a hospital employee (patient #1). Failure to investigate, analyze and take corrective actions when possible sexual assault has occurred can result in a failure to identify additional patients who may be affected and to prevent further patient harm.

Findings include:

1. Adult Protective Services (APS) reports were reviewed from December 2010 to present that involved allegations of sexual abuse by hospital employees. A total of nineteen (19) APS reports were found involving allegations of sexual abuse by hospital employees. All cases had been completed with a determination by the Chief Executive Officer (CEO)/designee if it was substantiated or not except for a recent report that was filed on 4/20/12, which is still under investigation, and the report involving patient #1 which was filed on 7/18/11.

2. Review of the Quality Assurance/Performance Improvement (QA/PI) from December 2010 to present lacked documentation of any review of the reported sexual assault of patient #1. Additionally, there were no reviews or analysis of what hospital operational or patient care processes may have failed or performed inadequately to allow the sexual assault of a patient by a hospital employee. There were no documented efforts to identify any additional patient who may have been affected. There were no actions taken to prevent this from ever reoccurring.

3. The Chief Compliance Officer was questioned on 4/23/12 at 1150 hours if QA/PI had reviewed the allegations of sexual abuse of patient #1 by a hospital employee. She stated there has been no review done due to the fact the patient advocate, who is not a hospital employee, told them the state police were conducting a criminal investigation and to keep this very confidential. Additionally, when asked if QA/PI had reviewed possible system failures that could allow an incident like this to occur she stated they had not done anything due to not wanting to impede a criminal investigation.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on document review and staff interview it was determined that the hospitals Quality Assurance program failed to ensure that all hospital operations and care processes are thoroughly reviewed and discussed with actions taken if indicated to ensure that all patients are maintained free from sexual abuse or assault by hospital employees. This deficient practice was identified in one (1) of nineteen (19) reports of patient sexual assault by a hospital employee (patient #1). Failure to investigate, analyze and take corrective actions when possible sexual assault has occurred can result in a failure to identify additional patients who may be affected and to prevent further patient harm.

Findings include:

1. Adult Protective Services (APS) reports were reviewed from December 2010 to present that involved allegations of sexual abuse by hospital employees. A total of nineteen (19) APS reports were found involving allegations of sexual abuse by hospital employees. All cases had been completed with a determination by the Chief Executive Officer (CEO)/designee if it was substantiated or not except for a recent report that was filed on 4/20/12, which is still under investigation, and the report involving patient #1 which was filed on 7/18/11.

2. Review of the Quality Assurance/Performance Improvement (QA/PI) from December 2010 to present lacked documentation of any review of the reported sexual assault of patient #1. Additionally, there were no reviews or analysis of what hospital operational or patient care processes may have failed or performed inadequately to allow the sexual assault of a patient by a hospital employee. There were no documented efforts to identify any additional patient who may have been affected. There were no actions taken to prevent this from ever reoccurring.

3. The Chief Compliance Officer was questioned on 4/23/12 at 1150 hours if QA/PI had reviewed the allegations of sexual abuse of patient #1 by a hospital employee. She stated there has been no review done due to the fact the patient advocate, who is not a hospital employee, told them the state police were conducting a criminal investigation and to keep this very confidential. Additionally, when asked if QA/PI had reviewed possible system failures that could allow an incident like this to occur she stated they had not done anything due to not wanting to impede a criminal investigation.