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 Nov. 16, 2016
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review, document review and staff interview it was determined the Chief Executive Officer (CEO) failed to ensure a complaint investigation for abuse was completed in one (1) of ten (10) complaints reviewed for abuse (patient #1). This failure has the potential for all patients who file a complaint of abuse to have a negative outcome.

1. Review of the complaint for patient #1 revealed the patient advocate office completed a complaint investigation but the facility failed to investigate the complaint.

2. Review of the policy titled "Allegations of Abuse and Neglect", last reviewed 3/2014, revealed in part: "The CEO/designee will also assign a hospital staff member(s) to investigate...abuse and/or neglect... the investigation will be complete within fourteen (14) calendar days of the investigation."

3. An interview on 11/15/16 at 1:10 p.m. with the CEO revealed no formal investigation was completed or documented on patient #1's complaint. He concurred with the above findings.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
Based on record review, document review and staff interview it was determined the hospital failed to ensure a physician completed a physical assessment on one (1) of one (1) patients that complained of an alleged rape (patient #1). This failure has the potential for all patients who complain of alleged rape to not receive adequate medical treatment.

1. Review of the medical record for patient #1 revealed on 10/31/16 during morning rounds she notified Doctor #1 that she was "raped last night". It further revealed no physical assessment was completed by the physician.

2. An interview was conducted on 11/14/16 at 9:50 a.m. with Doctor #1. When asked if she remembered the incident and if she completed a physical examination of the patient she stated, in part: "I do remember she told me during morning rounds that she was raped during night shift and no I did not complete a physical examination because I felt the patient was being untruthful."

3. Review of the policy titled "Abuse and Neglect", last reviewed 3/2014, revealed it states, in part: "Physical and psychological findings will be placed in the patient's medical record."

4. Review of the hospital by-laws titled "Rules and Regulations Governing Patient Management", last reviewed 10/2016, revealed it states, in part: "Progress notes must include a chronological record of patient's clinical course, including a description of change in the patient's condition."

5. An interview was conducted on 1/15/16 at 9:54 a.m. with the Medical Director. When asked his expectation of a physician completing a physical exam when a patient complains of an alleged rape, he stated, in part: "I would expect a physical exam to be done so you can see the whole picture if it happened or did not happen." He concurred with the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, document review and staff interview it was determined the Director of Nursing failed to ensure nursing staff completed a physical assessment when a patient alleged a rape by a staff member in one (1) of ten (10) medical records reviewed involving a patient complaining of abuse/rape (patient #1). This failure has the potential to negatively affect the health of any patient who complains of an alleged rape.

Findings include:

1. Review of medical record for patient #1 revealed she was admitted on [DATE] with a diagnosis of schizoaffective disorder. During morning rounds on 10/31/16, patient #1 stated to Doctor #1 and Registered Nurse (RN) #1 that she was raped by a male staff member during the night. No physical assessment was completed by RN #1 and no assessment was documented at the time of the incident.

2. An interview was conducted on 11/14/16 at 9:10 a.m. with RN #1. When asked if she remembered the incident and if she completed a physical assessment she stated, in part: "Yes, we were doing morning rounds when she complained of an alleged rape and Doctor #1 did not find the patient to be truthful."

3. Review of the policy titled "Abuse and Neglect", last reviewed 3/2014, revealed it states, in part: "The charge RN... will immediately asses the victim(s) for acute injury...physical and psychological findings will be placed in the patient's medical record."

4. An interview was conducted with the Chief Executive Officer on 11/14/16 at 1:30 p.m. and he concurred with the above findings.