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 July 1, 2015
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
Based on medical record review and staff interview it was determined the hospital failed to ensure restraints were used in accordance with the order of a physician or other licensed independent practitioner for two (2) out of ten (10) patients reviewed who were restrained (Patient #1 and Patient #2). This failure creates the potential for the misuse of restraints and can result in an adverse impact on the care and condition of all patients.

Findings include:

1. Review of the medical record for Patient #1 revealed she was restrained physically for a two (2) minute period on 5/5/15 and then placed in five (5) point restraints with four (4) point restraints placed on arms and legs and a chest posey placed on her torso.

Review of the physician's orders revealed no order for the 5/5/15 restraints. Progress notes from Physician #1 on 5/6/15 at 6:27 a.m. state: "Patient held 5/5/15 at 21:04 (9:04 p.m.) to 21:06 (9:06 p.m.) and mechanically from 21:06 (9:06 p.m.) to 21:40 (9:40 p.m.) due to aggression... Saw patient at 21:15 (9:15 p.m.)... I did not put the order in the computer because the computer was down yesterday." The record lacked a documented verbal order by nursing or a handwritten physician's order for the restraints used on Patient #1 on 5/5/15.

This documentation was reviewed and discussed with the Quality Director on 6/30/15 at 12:50 p.m. She agreed with the above findings.

2. Review of the medical record for Patient #2 revealed a Seclusion and Restraint Observation form dated 4/26/15 at 3:50 p.m. documenting the patient was placed in four (4) point mechanical restraints with a chest restraint. The restraint lasted until 7:50 p.m., at which time the patient was calm and agreed to safety. The record had a physician's order for the application of the four (4) point restraints on 4/26/15, but did not have orders for the chest restraint.

The Unit Manager of unit N-1 reviewed the above record on 6/30/15 at 1:30 p.m. and was unable to find a physician's order for the chest restraint applied to Patient #2 on 4/26/15.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
WV 714 2015-3-054

Based on medical record review, document review and staff interview it was determined the hospital failed to ensure allegations of abuse and neglect and steps taken to address allegations were documented in the medical record per policy for seven (7) out of ten (10) patients who had allegations of abuse and neglect filed (Patient #1, Patient #3, Patient #5, Patient #6, Patient #8, Patient #9 and Patient #10). This failure results in an incomplete medical records and increases the potential for abuse allegations to be inadequately addressed.

Findings include:

1. The current process for Identification, Reporting and Investigating Allegations of Abuse and Neglect was provided for review. These processes state, in part, under Reporting Alleged Abuse/Neglect: "The investigation process begins when there is a reported allegation that abuse or neglect may have occurred. The receipt of this information triggers a process for taking action to protect patients and employees and collecting information to determine facts... The Charge Registered Nurse (RN) or Nurse Clinical Coordinator (NCC) will immediately assess the victim(s) for acute injury and document physical and psychological findings in the medical record. The shift RN will notify medical staff and the NCC of Adult Protective Services (APS) of the allegation and document notifications in a progress note... A progress note in the patient's medical record should document the patient's account of the incident and that an APS report was filed."

Review of the Abuse Allegation file for the past three (3) months revealed an APS report filed on 5/5/15 regarding abuse allegations made by Patient #1 regarding an incident that occurred on 5/4/15.

Review of Patient #1's medical record revealed no documentation related to the abuse allegation which was made on 5/5/15. It further revealed no examination regarding the allegation, notification of the physician, notification of the NCC or the completion of an APS report as required per policy.

This documentation was reviewed and discussed with the Quality Director on 6/30/15 at 12:50 p.m. where she agreed with these findings.

2. Review of the Abuse Allegation file for the past three (3) months revealed an APS report was filed on 6/23/15 regarding abuse allegations with injuries made by Patient #3.

Review of the medical record for Patient #3 revealed no documentation related to the abuse allegation made on 6/23/15. It further revealed no notification of the physician, notification of the NCC or the completion of an APS report as required per policy.

3. Review of the Abuse Allegation file for the past three (3) months revealed an APS report filed on 5/20/15 regarding an abuse allegation with potential injuries by Patient #5. The abuse allegedly occurred on 5/18/15. It also contained an APS report filed on 4/13/15 regarding injuries to Patient #5 that occurred on 4/10/15.

Review of the medical record for Patient #5 revealed nursing documentation dated 4/10/15 and entered at 12:55 p.m. under the injuries section of a Restraint Report stating: "There is red rash and periorbital darkness around patient's eyes that became apparent during the previous seclusion but it is unknown what caused this. Patient states she doesn't remember anything happening to her facial area and denies pain or itching..." There was no documentation related to the abuse allegations which were made on 4/13/15 and 5/20/15. There were no examinations regarding the allegations, notifications of the physician or the NCC or the completion of an APS report as required per policy.

5. Review of the Abuse Allegation file for the past three (3) months revealed an APS report filed on 5/30/15 regarding an abuse allegation with injury to Patient #6. The abuse allegedly occurred on 5/29/15.

Review of the medical record for Patient #6 revealed no documentation related to the abuse allegation made on 5/30/15. The record lacked documentation of examination related to the allegation of injury, notification of the physician or the NCC or the completion of an APS report as required per policy.

6. Review of the Abuse Allegation file for the past three (3) months revealed a 5/22/15 APS report filed regarding an abuse allegation with potential injury to Patient #7. The abuse allegedly occurred on 5/20/15.

Review of 5/20/15 Seclusion and Restraint Observation Documentation for Patient #7 revealed Health Service Worker #4 documented, in part, the following at 8:55 p.m.: "Wanting a paper saying the support team punched him in his head."

Review of the medical record for Patient #7 revealed no documentation of examination regarding the allegation, notification of the physician or the NCC or the completion of an APS report as required per policy.

7. Review of the Abuse Allegation file for the past three (3) months revealed an APS report filed on 4/27/15 regarding an abuse allegation related to Patient #7. The abuse allegedly occurred on 4/15/14.

Review of the medical record for Patient #8 revealed no documentation of examination regarding the allegation, notification of the physician or the NCC or the completion of an APS report as required per policy.

8. Review of the Abuse Allegation file for the past three (3) months revealed an APS report filed on 4/28/15 regarding an abuse allegation related to Patient #10.

Review of the medical record for Patient #10 revealed no documentation of examination of the patient regarding the allegation, notification of the physician or the NCC or the completion of an APS report as required per policy.

These records were reviewed and discussed with the Director of Quality on 7/1/15 at 1:00 p.m. She agreed with the above findings.

Note: It must be noted the week following the completion of this investigation survey, the Office of Health Facility Licensure and Certification received three (3) additional complaints regarding patient rights issues concerning possible patient abuse that allegedly occurred on 5/17/15, 5/29/15 and 6/26/15. These three (3) additional complaints involved other patients not mentioned in the original complaint and consisted of similar allegations that were investigated during this complaint investigation survey.