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 27, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
The hospital failed to ensure that all patients were given care in a safe setting and that patients remained free from abuse. The G1 Health Service Worker and Charge Nurse failed to follow their policy of fifteen (15) minute patient safety checks on twenty-six (26) patients. Unit N2 Charge Nurse did not follow hospital policy to ensure fifteen (15) minute patient safety checks were completed on twenty-eight (28) patients and that patient #10 remained under Close Constant Observation as ordered. (See A-0144 and A-0145).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A. Based on record review, review of policies and staff interviews it was determined the hospital failed to follow hospital policies on every fifteen (15) minute hallway checks for patient safety for twenty-six (26) of twenty-six (26) patients on the G1 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

Findings include:

1. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. no hallway checks were completed on twenty-six (26) of twenty-six (26) patients on the G1 unit.

2. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

3. An interview was conducted on 7/27/16 at 1:20 p.m. with Programmer #1 who works on Unit G1. When asked if she failed to do hallway checks on 7/20/16 between the hours 10:45 p.m. through 11:15 p.m. she stated in part: "At the beginning of my shift they were changing assignments and I decided I would check later for my assignment and then I got busy doing other things and never checked my assignment again so I didn't realize I was assigned to do hallway checks and no one told me I was doing them".

4. An interview was conducted on 7/27/16 at 1:33 p.m. with the unit Nurse Manager (NM); she concurred with the above findings. An audio recording of Health Service Worker (HSW) #1 was presented during the interview and it revealed HSW #1 started to complete his 11:30 p.m. hallway checks when he noticed the checks were not completed and he informed the charge nurse.

B. Based on record review, review of policies, review of video monitoring and staff interviews it was determined the hospital failed to follow hospital policies of fifteen (15) minute hallway checks for patient safety for twenty-eight (28) of twenty-eight (28) patients on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #6 revealed a nursing note written by Registered Nurse (RN) #1 on 7/20/16 at 11:30 p.m. that states in part: "Staff informed patients to stay in their room as a safety precaution and staff was unable to perform usual duties, hallwalk or address other patients' requests due to the threat of being attacked".

2. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. no hallway checks were completed on twenty-eight (28) of twenty-eight (28) patients on the N2 unit, the checksheet is marked through by RN #1 with notations of no hallwalk crisis for the time period listed above.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

4. Review of video monitoring on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. revealed an altercation between patient #6 and patient #8. Patient #6 was seen on video sitting in the common area in a calm manner at 11:08 p.m. Patient #6 went to his room at 11:13 p.m. and seven (7) staff remained behind the nursing station until 11:20 p.m.

5. An interview on 7/26/16 at 3:30 p.m. with The N2 Evening Charge Nurse (Registered Nurse #1) revealed in part she remembered the above incident and her decision to not allow staff to complete assigned hallway checks because they were scared of patient #6. It further revealed she did not contact patient #6's physician for any orders or to inform him she had made a decision to stop hallway checks. RN #1 stated in part: "We were scared, he has a reputation of being a dangerous patient so I decided that no hallway checks should be done and everyone to remain behind the nursing station for our safety". When asked how long she held hallway checks she stated: "9:30 p.m. to 11:00 p.m.".

6. A joint interview was conducted on 7/27/16 at 9:34 a.m. with Doctor #2 and the Medical Director. Doctor #2 remembered the altercation between patient #6 and patient #8 on 7/20/16. He stated when he got in the next morning he was told about it. When asked
if he was contacted by RN #1 for a no hallway check order due to her belief the staff was in harms way due to a crisis of patient (Patient #6), he stated: "No one called me for him I had no clue everyone on the unit was not being checked. I'd never give an order for no hallway checks that leaves the other patients at risk of harm. If I would have known I'd have given an order for my patient (Patient #6)." The medical Director agreed patient #6 should have been treated if the nursing staff felt the patient was still in a crisis mode and the other patients should not have been put at risk for harm by no hallway checks.

7. A joint interview was conducted on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer and they concurred with the above findings.

C. Based on medical record review, review of video monitoring, review of policies and staff interviews it was determined the hospital failed to follow hospital policies on Close Constant Observation (CCO) on one (1) of one (1) of patients (patient #10) on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #10 revealed a physician's order written on 5/25/16 at 2:32 p.m. for two (2) to one (1) CCO for suicide risk.

2. Video monitoring was reviewed on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. and again on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer for the N2 unit for the night of 7/20/2016 for the hours of 9:34 p.m. through 10:15 p.m. The video revealed in part a physical altercation between two patients (patient #6 and patient #8). It was noted in the video two (2) Health Service Workers (HSW) came out of patient #10's room (located in the seclusion room for Patient #10's safety) and into an ante room and opened the door and came into the hallway at 9:35:09 p.m. Patient #10 on the identifier list can be seen exiting her room and entering the hallway at 9:36:22 p.m. and placing a hand on HSW #2's shoulder. During the time both HSWs were in the hallway patient #10 was not observed. They both concurred the patient was not monitored for the time listed.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part: "Requires a physician's order that includes the indication for CCO...A patient on this level of observation must always be in view of the staff member assigned to the observation...Staff will make sure there is no barrier between them and the patient during observation".

4. An interview was conducted with HSW #3 on 7/27/16 at 12:00 p.m. revealed in part, when asked if she remembered the night of the altercation between patient #6 and patient #8 she stated in part: "Yes, I was on CCO with patient #10, she requires two people to sit with her for her safety". When asked if she ever left patient #10 and if so why she stated: "No, she's a harm to herself and I would never leave her". When I explained this surveyor watched a video of the altercation and saw that she and HSW #2 both left the patient's room and the ante room. She stated: "I wouldn't do that, she's very fast when she wants to hurt herself". HSW #3 requested to see the video and the request was granted in the presence of this surveyor and the Director of Safety. She concurred both HSW #2 and HSW #3 left the patient unattended.

5. An attempt to interview HSW #2 was made and she was unavailable.

6. A joint interview with Doctor #1 and the Medical Director was conducted on 7/27/16 at 9:34 a.m. When Doctor #1 was asked to explain his CCO of two (2) to one (1) for patient #10 he stated in part: "She is a danger to herself, she can't be left alone for any amount of time, she will hurt herself very fast". When this surveyor explained I had reviewed the video for the night of 7/20/16 and the video showed patient #10 being left alone on the video for a little over one and one half (1 ) minutes, he stated that was too long she can hurt herself very fast. The Medical Director agreed that was too long "she hurts herself in seconds".
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
A. Based on record review, review of policies and staff interviews it was determined the hospital failed to follow hospital policies of every fifteen (15) minute hallway checks for patient safety for twenty-six (26) of twenty-six (26) patients on the G1 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

Findings include:

1. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. revealed no hallway checks were completed on twenty-six (26) of twenty-six (26) patients on the G1 unit.

2. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

3. An interview was conducted on 7/27/16 at 1:20 p.m. with Programmer #1 who works on Unit G1. When asked if she failed to do hallway checks on 7/20/16 between the hours 10:45 p.m. through 11:15 p.m. she stated in part: "At the beginning of my shift they were changing assignments and I decided I would check later for my assignment and then I got busy doing other things and never checked my assignment again so I didn't realize I was assigned to do hallway checks and no one told me I was doing them".

4. An interview was conducted on 7/27/16 at 1:33 p.m. with the unit Nurse Manager (NM); she concurred with the above findings. An audio recording of Health Service Worker (HSW) #1 was presented during the interview and it revealed HSW #1 started to complete his 11:30 p.m. hallway checks when he noticed the checks were not completed and he informed the charge nurse.

B. Based on record review, review of policies, review of video monitoring and staff interviews it was determined the hospital failed to follow hospital policies on every fifteen (15) minute hallway checks for patient safety for twenty-eight (28) of twenty-eight (28) patients on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #6 revealed a nursing note written by Registered Nurse (RN) #1 on 7/20/16 at 11:30 p.m. that states in part: "Staff informed patients to stay in their room as a safety precaution and staff was unable to perform usual duties, hall walk or address other patients' requests due to the threat of being attacked".

2. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. no hallway checks were completed on twenty-eight (28) of twenty-eight (28) patients on the N1 unit; the checksheet is marked through by RN #1 with notations of no hallwalk crisis for the time period listed above.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part: "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

4. Review of video monitoring on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. revealed an altercation between patient #6 and patient #8. Patient #6 was seen on video sitting in the common area in a calm manner at 11:08 p.m. patient #6 went to his room at 11:13 p.m. and seven (7) staff remained behind the nursing station until 11:20 p.m.

5. An interview on 7/26/16 at 3:30 p.m. with The N1 Evening Charge Nurse (Registered Nurse #1) revealed in part she remembered the above incident and her decision to not allow staff to complete assigned hallway checks because they were scared of patient #6. It further revealed she did not contact patient #6's physician for any orders or to inform him she had made a decision to stop hallway checks. RN #1 stated in part: "We were scared he has a reputation of being a dangerous patient so I decided that no hallway checks should be done and everyone to remain behind the nursing station for our safety". When asked how long she held hallway checks she stated: "10:45 p.m. to 11:00 p.m.".

6. A joint interview was conducted on 7/27/16 at 9:34 a.m. with Doctor #2 and the Medical Director. Doctor #2 remembered the altercation between patient #6 and patient #8 on 7/20/16. He stated in part when he got in the next morning he was told about it. When asked if he was contacted by RN #1 for a no hallway check order due to her belief the staff was in harm's way due to a crisis of patient (Patient #6). He stated: "No one called me for him I had no clue everyone on the unit was not being checked. I'd never give an order for no hallway checks that leaves the other patients at risk of harm, if I would have known I'd have given an order for my patient (Patient #6). The medical Director agreed patient #6 should have been treated if the nursing staff felt the patient was still in a crisis mode and the other patients should not have been put at risk for harm by no hallway checks.

7. A joint interview was conducted on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer and they concurred with the above findings.

C. Based on medical record review, review of video monitoring, review of policies and staff interviews it was determined the hospital failed to follow hospital policies on Close Constant Observation (CCO) on one (1) of one (1) of patients (patient #10) on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #10 revealed a physician's order written on 5/25/16 at 2:32 p.m. for two (2) to one (1) CCO for suicide risk.

2. The video monitoring was reviewed on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. and again on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer for the N1 unit for the night of 7/20/2016 for the hours of 9:34 p.m. through 10:15 p.m. The video revealed in part a physical altercation between two (2) patients (patient #6 and patient #8). It was noted in the video two (2) Health Service Workers (HSW) came out of patient #10's room (located in the seclusion room for Patient #10's safety) and into an ante room and opened the door and came into the hallway at 9:35:09 p.m. Patient #10 on the identifier list can be seen exiting her room and entering the hallway at 9:36:22 p.m. and placing a hand on HSW #2's shoulder. During the time both HSWs were in the hallway patient #10 was not observed. They both concurred the patient was not monitored for the time listed.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part, "Requires a physician's order that includes the indication for CCO...A patient on this level of observation must always be in view of the staff member assigned to the observation...Staff will make sure there is no barrier between them and the patient during observation".

4. An interview was conducted with HSW #3 on 7/27/16 at 12:00 p.m. revealed in part when asked to if she remembered the night of the altercation between patient #6 and patient #8 she stated in part: "Yes, I was on CCO with patient #10 she requires two people to sit with her for her safety". When asked if she ever left patient #10 and if so why she stated: "No, she's a harm to herself and I would never leave her". When I explained this surveyor watched a video of the altercation and saw that she and HSW #2 both left the patient's room and the ante room. She stated: "I wouldn't do that, she's very fast when she wants to hurt herself". HSW #3 requested to see the video and the request was granted in the presence of this surveyor and the Director of Safety. She concurred both HSW #2 and HSW #3 left the patient unattended.

5. An attempt to interview HSW #2 was made and she was unavailable.

6. A joint interview with Doctor #1 and the Medical Director was conducted on 7/27/16 at 9:34 a.m. When Doctor #1 was asked to explain his CCO of two (2) to one (1) for patient #10 he stated in part: "She is a danger to herself, she can't be left alone for any amount of time, she will hurt herself very fast". When this surveyor explained I had reviewed the video for the night of 7/20/16 and the video showed patient #10 being left alone on the video for a little over one and one half minutes (1 ) he stated that was too long she can hurt herself very fast. The Medical Director agreed that was too long "she hurts herself in seconds".
VIOLATION: NURSING SERVICES Tag No: A0385
The Director of Nursing failed to ensure nursing personnel filed an Adult Protective Service Order for one (1) of one (1) patients (patient #8) who were harmed during a physical altercation with another patient (patient #6) and to ensure the Adult Protective Service Order was filed on twenty-eight (28) of twenty-eight (28) patients neglected due to no hallway checks on unit N2. (See A-0386).


The Director of Nursing failed to ensure supervision of nursing care related to incomplete hallway safety checks on unit G1 for twenty-six (26) of twenty-six (26) patients and N2 for twenty-eight (28) of twenty-eight (28) patients and one (1) of one (1) patients on Close Constant Observation on unit N2. (See A-395).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
A. Based on record review, review of policies, review of video monitoring and staff interviews it was determined the hospital failed to follow hospital policies of every fifteen (15) minute hallway checks for patient safety for twenty-eight (28) of twenty-eight (28) patients on the N2 unit. This failure has the potential for all patients with a diagnosis of suicidal ideations, homicidal ideations, psychosis and sexually inappropriate behavior diagnosis to cause harm to themselves or others.

1. Review of the medical record for patient #6 revealed a nursing note written by Registered Nurse (RN) #1 on 7/20/16 at 11:30 p.m. that states in part: "Staff informed patients to stay in their room as a safety precaution and staff was unable to perform usual duties, hallwalk or address other patients' requests due to the threat of being attacked".

2. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. no hallway checks were completed on twenty-eight (28) of twenty-eight (28) patients on the N2 unit. The checksheet is marked through by RN #1 with notations of no hallwalk crisis for the time period listed above.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

4. Review of the policy titled "Allegation of Abuse and Neglect", with a last revision date of 3/2014, states in part: "Reporting Alleged Abuse/Neglect...The shift RN will contact the Nurse Clinical Coordinator (NCC) of Adult Protective Service (APS) allegations document notification in the progress notes...Immediately complete S form".

5. Review of video monitoring on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. revealed an altercation between patient #6 and patient #8. Patient #6 was seen on video sitting in the common area in a calm manner at 11:08 p.m. Patient #6 went to his room at 11:13 p.m. and seven (7) staff remained behind the nursing station until 11:20 p.m.

6. An interview on 7/26/16 at 3:30 p.m. with The N2 Evening Charge Nurse (Registered Nurse #1) revealed in part she remembered the above incident and her decision to not allow staff to complete assigned hallway checks because they were scared of patient #6. It further revealed she did not contact patient #6's physician for any orders or to inform him she had made a decision to stop hallway checks. RN #1 stated in part: "We were scared he has a reputation of being a dangerous patient, so I decided that no hallway checks should be done and everyone to remain behind the nursing station for our safety. " When asked how long she held hallway checks she stated: "9:30 p.m to 11:00 p.m.". When asked if she filed an Adult Protective Service (APS) Order for Patient #8 she stated: "No, I didn't know I had to".

7. A joint interview was conducted on 7/27/16 at 9:34 a.m. with Doctor #2 and the Medical Director. Doctor #2 remembered the altercation between patient #6 and patient #8 on 7/20/16. He stated in part when he got in the next morning he was told about it. When asked if he was contacted by RN #1 for a no hallway check order due to her belief the staff was in harm's way due to a crisis of patient (Patient #6). He stated: "No one called me for him I had no clue everyone on the unit was not being checked. I'd never give an order for no hallway checks that leaves the other patients at risk of harm, if I would have known I'd have given an order for my patient (Patient #6). The medical Director agreed patient #6 should have been treated if the nursing staff felt the patient was still in a crisis mode and the other patients should not have been put at risk for harm by no hallway checks.

8. A joint interview was conducted on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer and they concurred with the above findings and that no APS order was filed.

9. A telephone interview was conducted with the Assistant Director of Nursing on 7/27/16 at 3:00 p.m. when asked if they had filed an APS order for patient #8 or for neglect of all patients on unit G1 and N2 for the night of 7/20/16 for failure to monitor patients from the hours 10:45 p.m. through 11:15 p.m. she stated: "That isn't our practice to complete one on patient to patient but we did file one on hallway checks yesterday for unit N2 we had already completed one for G1".

B. Based on medical record review, review of video monitoring, review of policies and staff interviews it was determined the Director of Nursing failed to ensure hospital policies were followed on Close Constant Observation (CCO) on one (1) of one (1) of patients (patient #10) on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #10 revealed a physician's order written on 5/25/16 at 2:32 p.m. for two (2) to one (1) CCO for suicide risk.

2. Review of video monitoring on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. and again on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive officer for the N1 unit for the night of 7/20/2016 for the hours of 9:34 p.m. through 10:15 p.m. The video revealed in part a physical altercation between two (2) patients (patient #6 and patient #8). It was noted in the video two (2) Health Service Workers (HSWs) came out of a patient #10's room (located in the seclusion room for Patient #10's safety) and into an ante room and opened the door and came into the hallway at 9:35:09 p.m. Patient #10 on the identifier list can be seen exiting her room and entering the hallway at 9:36:22 p.m. and placing a hand on HSW #2's shoulder. During the time both HSWs were in the hallway patient #10 was not observed. They both concurred the patient was not monitored for the time listed. The Chief Executive Officer concurred no APS order was filed.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Requires a physician's order that includes the indication for CCO...A patient on this level of observation must always be in view of the staff member assigned to the observation...Staff will make sure there is no barrier between them and the patient during observation".

4. Review of the policy titled "Allegation of Abuse and Neglect", with a last revision date of 3/2014, states in part "Reporting Alleged Abuse/Neglect...The shift RN will contact the Nurse Clinical Coordinator (NCC) of Adult Protective Service (APS) allegations document notification in the progress notes...Immediately complete S form".


5. An interview was conducted with HSW #3 on 7/27/16 at 12:00 p.m. revealed in part when asked to if she remembered the night of the altercation between patient #6 and patient #8 she stated in part: "Yes, I was on CCO with patient #10 she requires two people to sit with her for her safety. " When asked if she ever left patient #10 and if so why she stated: "No, she's a harm to herself and I would never leave her". When I explained this surveyor watched a video of the altercation and saw that she and HSW #2 both left the patient's room and the ante room. She stated: "I wouldn't do that, she's very fast when she wants to hurt herself". HSW #3 requested to see the video and the request was granted in the presence of this surveyor and the Director of Safety. She concurred both HSW #2 and HSW #3 left the patient unattended.

6. An attempt to interview HSW #2 was made and she was unavailable.

7. A joint interview with Doctor #1 and the Medical Director was conducted on 7/27/16 at 9:34 a.m. When Doctor #1 was asked to explain his CCO of two (2) to one (1) for patient #10 he stated in part: "She is a danger to herself, she can't be left alone for any amount of time, she will hurt herself very fast." When this surveyor explained I had reviewed the video for the night of 7/20/16 and the video showed patient #10 being left alone on the video for a little over one and one half minutes (1 ) he stated that was too long she can hurt herself very fast. The Medical Director agreed that was too long "she hurts herself in seconds".

C. Based on medical record review, review of policies and staff interview it was determined The Director of Nursing failed to ensure Registered Nurse #1 completed an Adult Protective Service order for one (1) of one (1) patients (patient #8) who was in an altercation with another patient. This failure has the potential to place all patients in a physical altercation with other patients and not be protected to the fullest extent of the law.

1. Review of the medical record for patient #8 revealed the patient was physically attacked by patient #6 on 7/20/16 at approximately 9:30 p.m. She was transported to Stonewall Jackson Memorial Hospital at approximately 10:20 p.m. and returned to William R. Sharpe, Jr. Hospital at 12:55 a.m. on 7/21/16 with a fractured nose and multiple bruises on her face, chest, stomach and arms.

2. Review of the policy titled "Allegation of Abuse and Neglect", with a last revision date of 3/2014, states in part: "Reporting Alleged Abuse/Neglect...The shift RN will contact the Nurse Clinical Coordinator (NCC) of Adult Protective Service (APS) allegations and document notification in the progress notes...Immediately complete the APS form".

3. An interview on 7/26/16 at 3:30 p.m. with The N2 Evening Charge Nurse (Registered Nurse #1) revealed in part she remembered the above incident and failed to file an APS order for patient #8.

4. A telephone interview was conducted with the Assistant Director of Nursing on 7/27/16 at 3:00 p.m. when asked if they had filed an APS order for patient #8 and the physical abuse she endured from patient #6 she stated in part: "That isn't our practice to complete one on patient to patient physical abuse".

5. An interview was conducted with the Chief Executive Officer (CEO) on 7/27/16 at 3:10 p.m. and he concurred no APS form was filed on behalf of patient #8.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
A. Based on record review, review of policies and staff interviews the director of nursing failed to ensure nursing personnel completed every fifteen (15) minute hallway checks for patient safety for twenty-six (26) of twenty-six (26) patients on the G1 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

Findings include:

1. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. no hallway checks were completed on twenty-six (26) of twenty-six (26) patients on the G1 unit.

2. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

3. An interview was conducted on 7/27/16 at 1:20 p.m. with Programmer #1 who works on Unit G1. When asked if she failed to do hallway checks on 7/20/16 between the hours 10:45 p.m. through 11:15 p.m. she stated in part: "At the beginning of my shift they were changing assignments and I decided I would check later for my assignment and then I got busy doing other things and never checked my assignment again so I didn't realize I was assigned to do hallway checks and no one told me I was doing them".

4. An interview was conducted on 7/27/16 at 1:33 p.m. with the unit Nurse Manager (NM); she concurred with the above findings. An audio recording of Health Service Worker (HSW) #1 was presented during the interview and it revealed HSW #1 started to complete his 11:30 p.m. hallway checks when he noticed the checks were not completed and he informed the charge nurse.

B. Based on record review, review of policies, review of video monitoring and staff interviews it was determined the Director of Nursing failed to ensure nursing personnel followed hospital policies of every fifteen (15) minute hallway checks for patient safety for twenty-eight (28) of twenty-eight (28) patients on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #6 revealed a nursing note written by Registered Nurse (RN) #1 on 7/20/16 at 11:30 p.m. that states in part: "Staff informed patients to stay in their room as a safety precaution and staff was unable to perform usual duties, hall walk or address other patients' requests due to the threat of being attacked".

2. Review of the checksheet titled "Patient Location/Activity Checksheet" for 7/20/16 for the time period of 10:45 p.m. through 11:15 p.m. revealed no hallway checks were completed on twenty-eight (28) of twenty-eight (28) patients on the N2 unit. The checksheet is marked through by RN #1 with notations of no hallwalk crisis for the time period listed above.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part: "Hallway walk occurs every fifteen (15) minutes...Observation is recorded on the patient location/activity sheet".

4. Review of video monitoring on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. revealed an altercation between patient #6 and patient #8. Patient #6 was seen on video sitting in the common area in a calm manner at 11:08 p.m. Patient #6 went to his room at 11:13 p.m. and seven (7) staff remained behind the nursing station until 11:20 p.m.

5. An interview on 7/26/16 at 3:30 p.m. with The N2 Evening Charge Nurse (Registered Nurse #1) revealed in part she remembered the above incident and her decision to not allow staff to complete assigned hallway checks because they were scared of patient #6, it further revealed she did not contact patient #6's physician for any orders or to inform him she had made a decision to stop hallway checks. RN #1 stated in part: "We were scared he has a reputation of being a dangerous patient, so I decided that no hallway checks should be done and everyone to remain behind the nursing station for our safety". When asked how long she held hallway checks she stated: "9:30 p.m. to 11:00 p.m.".

6. A joint interview was conducted on 7/27/16 at 9:34 a.m. with Doctor #2 and the Medical Director. Doctor #2 remembered the altercation between patient #6 and patient #8 on 7/20/16. He stated in part when he got in the next morning he was told about it. When asked if he was contacted by RN #1 for a no hallway check order due to her belief the staff was in harm's way due to a crisis of patient (Patient #6). He stated: "No one called me for him I had no clue everyone on the unit was not being checked. I'd never give an order for no hallway checks that leaves the other patients at risk of harm, if I would have known I'd have given an order for my patient (Patient #6). The Medical Director agreed patient #6 should have been treated if the nursing staff felt the patient was still in a crisis mode and the other patients should not have been put at risk for harm by no hallway checks.

7. A joint interview was conducted on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer and they concurred with the above findings.

C. Based on medical record review, review of video monitoring, review of policies and staff interviews it was determined the Director of Nursing failed to ensure nursing personnel followed hospital policies on Close Constant Observation (CCO) of one (1) of one (1) of patients (patient #10) on the N2 unit. This has the potential for all patients to have the ability to cause self harm or harm to others.

1. Review of the medical record for patient #10 revealed a physician's order written on 5/25/16 at 2:32 p.m. for two (2) to one (1) CCO for suicide risk.

2. Video monitoring was reviewed on 7/26/16 at 2:30 p.m. with the Director of Safety for the night of 7/20/16 for the hours of 9:30 p.m. through 11:30 p.m. and again on 7/27/16 at 8:45 a.m. with the Director of Safety and the Chief Executive Officer for the N2 unit for the night of 7/20/2016 for the hours of 9:34 p.m. through 10:15 p.m. The video revealed in part a physical altercation between two (2) patients (patient #6 and patient #8). It was noted in the video two (2) Health Service Workers (HSW) came out of a patient #10's room (located in the seclusion room for Patient #10's safety) and into an ante room and opened the door and came into the hallway at 9:35:09 p.m. Patient #10 on the identifier list can be seen exiting her room and entering the hallway at 9:36:22 p.m. and placing a hand on HSW #2's shoulder. During the time both HSWs were in the hallway patient #10 was not observed. They both concurred the patient was not monitored for the time listed.

3. Review of the policy titled "Levels of Observation", with a last revision date of 1/2016, states in part "Requires a physician's order that includes the indication for CCO...A patient on this level of observation must always be in view of the staff member assigned to the observation...Staff will make sure there is no barrier between them and the patient during observation".

4. An interview was conducted with HSW #3 on 7/27/16 at 12:00 p.m. revealed in part when asked to if she remembered the night of the altercation between patient #6 and patient #8 she stated in part: "Yes, I was on CCO with patient #10 she requires two people to sit with her for her safety". When asked if she ever left patient #10 and if so why she stated: "No, she's a harm to herself and I would never leave her". When I explained this surveyor watched a video of the altercation and saw that she and HSW #2 both left the patient's room and the ante room. She stated: "I wouldn't do that, she's very fast when she wants to hurt herself". HSW #3 requested to see the video and the request was granted in the presence of this surveyor and the Director of Safety. She concurred both HSW #2 and HSW #3 left the patient unattended.

5. An attempt to interview HSW #2 was made and she was unavailable.

6. A joint interview with Doctor #1 and the Medical Director was conducted on 7/27/16 at 9:34 a.m. When Doctor #1 was asked to explain his CCO of two (2) to one (1) for patient #10 he stated in part: "She is a danger to herself, she can't be left alone for any amount of time, she will hurt herself very fast". When this surveyor explained I had reviewed the video for the night of 7/20/16 and the video showed patient #10 being left alone on the video for a little over one and one half minutes (1 ) he stated that was too long she can hurt herself very fast. The Medical Director agreed that was too long "she hurts herself in seconds".