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 Feb. 15, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
WV 200 2017-3-006

A. Based on observation and staff interview it was determined the hospital failed to utilize hospital beds which are free from potential tie off and ligature risk. This failure involved sixteen (16) hospital beds and creates an increased risk of hanging/strangulation and results in an unsafe setting for all patients who have access to these beds. Sixteen (16) of twenty-five (25) patients on this unit were utilizing the beds (patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17) but all patients on the unit had access to the beds.

Findings include:

1. A tour and observation was conducted on the C 2 Unit between approximately 1:30 p.m. and 2:30 p.m. on 2/13/17. The surveyor was accompanied by the Lead Nurse during the tour. The unit had a census of twenty-five (25) patients at the time of the tour and all patient bedrooms were observed. Patients #2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16 and 17 were all observed to have hospital beds. The beds had long electrical cords (approximately six (6) to eight (8) feet) which posed a risk for use as ligature devices. Ten (10) of the hospital beds (patients #2, 5, 6, 8, 12, 13, 14, 15, 16 and 17) had open side rails which posed a tie off risk for ligature attempts. Some of the beds/rooms had other medical devices, such as bed alarms, air mattresses and oxygen tubing with long cords which also posed a risk.

2. An interview was conducted with the Lead Nurse during the tour and she agreed with the above findings.





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B. Based on record review, document review, and staff interview it was determined the facility failed to ensure all patient care at the facility was provided in a safe manner by staff in one (1) of four (4) patients who were taken outdoors for fresh air (patient #1). This failure has the potential to negatively impact all patients when staff fail to ensure patients are supervised at all times.

Findings include:

1. The facility self-reported an incident on 12/26/16 when Registered Nurse (RN) #1 and Health Service Worker (HSW) #1 took four (4) patients to an outdoor courtyard for fresh air and returned without patient #1, leaving him alone in the courtyard. A review of the Root Cause Analysis which the facility completed immediately following the incident revealed both staff admitted to leaving patient #1 unattended in the outdoor courtyard on 12/26/16.

2. The facility policy entitled "Patient location/Activity", last reviewed 1/4/16, revealed the procedure for taking patients off of the unit for an activity. It stated, in part: "Form D will be taken to Off Unit Activities that include Fresh Air and Recreation Hall...As each patient leaves the activity site the responsible person will initial the appropriate section. A patient count will be done as patients enter the unit upon returning from an activity site."

3. A review of patient #1's clinical record revealed on 12/26/16 at about 12:45 p.m. the patient was documented on Form D to have left the facility unit/floor, designated as 'G 2', with two (2) staff, HSW #1 and RN #1. It was also documented by HSW #1 that patient #1 returned to the unit at about 1:30 p.m.

4. In an interview on 2/14/17 at about 2:23 p.m. with the Licensed Practical Nurse from unit N 1, he stated he was walking in the hallway by the outdoor courtyard and patient #1 flagged him down and told him staff had left him alone in the courtyard. He called the supervisor and the supervisor took charge and returned the patient to his own unit at about 2:00 p.m.

5. HSW #1 was interviewed on 2/13/17 at about 11:21 a.m. and the above incident was discussed. She stated she was one of the staff members that left patient #1 in the outdoor courtyard when they returned to the unit. She also stated she mistakenly documented patient #1 returned to the unit with the group and that she miscounted the patients when they returned to the unit.

6. RN #1 was interviewed on 2/14/17 at about 11:00 a.m. and the above incident was discussed. She stated she went to the outdoor courtyard with HSW #1 and four (4) patients. She stated '[patient #1] got left behind' when they returned to the unit. It was not discovered until he was returned to the unit about twenty (20) minutes after they got back to the unit when a supervisor returned patient #1 to the unit unharmed. RN #1 stated she was not the staff designated to complete Form D but admitted as the RN she was responsible to evaluate and supervise patient #1's care, including outdoor trips.

7. The Director of Nursing was interviewed on 2/14/17 at about 3:28 p.m. The above incident was discussed and she stated the staff responsible for the situation had issues with accountability. She stated she could not believe patient #1 was left out in the courtyard without staff to ensure he was as safe as possible.

8. The Chief Compliance Officer was interviewed on 2/13/17 at about 1:11 p.m. and the above incident was discussed. She stated she was the administrative person in charge that day. She stated she was called due to the possibility of patient abuse and that staff was removed from patient care until an answer was found to the question of adequate patient safety. She stated they completed a Root Cause Analysis and determined RN #1 and HSW #1 were responsible for patient #1's safety and they did not follow facility policy in that regard.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
WV 200 2017-3-006

Based on document review, record review and staff interview it was determined staff failed to follow policy related to identification, reporting and investigating allegations of abuse. This deficient practice was identified in one (1) of two (2) records reviewed on the C 2 Unit with allegations of abuse (patient #1). This failure increases the potential for abuse for all patients.

Findings include:

1. The policy titled "The Process for Identification, Reporting, Investigating Allegations of Abuse and Neglect and Patient Grievance", effective 6/2008, was provided for review. It stated, in part: "Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse and/or Nurse Manager assigned to the unit where the patient resides or to the Nurse Clinical Coordinator (NCC). Documentation in the form of an APS [Adult Protective Services] form, incident report, progress note, grievance form, and/or written statements are to be completed and provided to the Nursing Clinical Coordinator by employees reporting allegations of abuse/neglect within one hour of the allegation...The receipt of this information triggers a process for taking action to protect patients and employees and collecting information to determine facts. In all cases, the emphasis is on finding facts and taking appropriate action to protect all parties, including patients who may be victims of abuse and neglect and individuals who may be unfairly accused...The Charge RN or NCC will immediately assess the victim(s) for acute injury. Document physical and psychological findings in the medical record. The shift RN will notify medical staff and the NCC of APS allegation and document notifications in a progress note...If photographs need taken or other evidence needs to be secured, Security must be notified. Identify the alleged perpetrator(s) and remove them from the situation while the preliminary assessment is being completed. Immediately notify the charge RN and NCC. Identify any possible witnesses, including patients, staff, visitors, etc...Immediately complete an APS reporting form."

2. Review of the 1/4/17 APS form completed for patient #1 revealed the incident of alleged abuse occurred on 12/30/16. Review of the clinical record for patient #1 revealed Registered Nurse (RN) #1 failed to document an assessment of the patient related to the abuse allegation made on 12/30/16. The record lacked documentation of the allegation or any other documentation to reflect the RN initiated the Abuse Reporting and Investigation process as required.

3. Interview with Health Service Worker (HSW) #2 on 2/13/17 at 2:15 p.m. revealed RN #1 was aware of the abuse allegation during the evening shift of 12/30/16.

4. Interview with HSW #4 on 2/14/17 at 3:30 p.m. revealed RN #1 was aware of the abuse allegation during the evening shift of 12/30/16.

5. Review of the hospital investigation into the abuse allegation revealed RN #1 confirmed she was aware of the abuse allegation during the evening shift of 12/30/16.

6. The above findings were reviewed and discussed with the Assistant Chief Nursing Officer at 9:30 a.m. on 2/15/17. She acknowledged RN #1 should have initiated the Abuse Reporting and Investigation Process on 12/30/16.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
WV 200 2017-3-006

A. Based on document review, record review and staff interview it was determined the registered nurse (RN) failed to supervise and evaluate the nursing care for one (1) of one (1) patients reviewed who pulled/broke a tooth and subsequently developed a dental infection (patient #1). This failure resulted in an adverse impact to the patient's health and may result in an adverse impact on the health of any patients requiring nursing assessment, follow-up and medical referral.

Finding include:

1. The policy "Incident Reporting and Review", effective 1/15/15, was provided for review. The policy states, in part: "Incident Reports must be completed when: A. There is an injury (regardless of severity) to patient, employee or visitors...B. The Charge Nurse must assure that the attending physician or designee has been notified, family contacts have been made (See Note), Progress Notes completed, and the Incident Report form is accurately completed and signed."

2. Review of the clinical record for patient #1 revealed RN #1 documented on 12/10/16 at 9:10 a.m., in part: "Health Service Worker came to this nurse and reported this patient had pulled her tooth. This nurse observed the tooth to be half in size." The record lacked documentation to reflect this was referred to the physician for follow-up and/or treatment. No incident/occurrence form was completed per policy. The record lacked a nursing assessment or reassessment of the patient's broken tooth.

On 12/30/16 at 9:36 a.m., the day-shift RN documented the patient's right jaw was swollen due to a dental infection. An oral antibiotic was ordered and started on that date. The patient continued to be on the antibiotic for a dental infection at the time she left the facility for medical treatment on 1/5/17. The record lacked any documentation of a medical or dental exam related to the dental infection prior to her transfer to another facility for medical treatment.

3. The above findings were reviewed and discussed with the Chief Nursing Officer 10:00 a.m. on 2/14/16 and she agreed with the findings.

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B. Based on document review, record review and staff interview it was determined the registered nurse (RN) failed to assess a patient for injury following an allegation of abuse. This failure involved one (1) of one (1) patients reviewed who was alleged to have been abused during administration of medication (patient #1) and creates a potential for an adverse impact on the care and condition of all patients.

Finding include:

1. The policy titled "The Process for Identification, Reporting, Investigating Allegations of Abuse and Neglect and Patient Grievance", effective 6/2008, was provided for review. It stated, in part: "Individuals who witness or have knowledge of patient abuse/neglect shall immediately report it to the charge nurse and/or Nurse Manager assigned to the unit where the patient resides or to the Nurse Clinical Coordinator (NCC). Documentation in the form of an APS [Adult Protective Services] form, incident report, progress note, grievance form, and/or written statements are to be completed and provided to the Nursing Clinical Coordinator by employees reporting allegations of abuse/neglect within one hour of the allegation...The receipt of this information triggers a process for taking action to protect patients and employees and collecting information to determine facts. In all cases, the emphasis is on finding facts and taking appropriate action to protect all parties, including patients who may be victims of abuse and neglect and individuals who may be unfairly accused...The Charge RN or NCC will immediately assess the victim(s) for acute injury. Document physical and psychological findings in the medical record. The shift RN will notify medical staff and the NCC of APS allegation and document notifications in a progress note...If photographs need taken or other evidence needs to be secured, Security must be notified. Identify the alleged perpetrator(s) and remove them from the situation while the preliminary assessment is being completed. Immediately notify the charge RN and NCC. Identify any possible witnesses, including patients, staff, visitors, etc...Immediately complete an APS reporting form."

2. Review of the 1/4/17 APS report completed for patient #1 revealed an incident of alleged abuse occurred on the evening of 12/30/16 during evening medication pass. Review of the clinical record for patient #1 revealed RN #1 failed to document an assessment of the patient related to the abuse allegation made on the evening of 12/30/16.

Review of the evening shift nursing assessment of patient #1 revealed it was recorded at 4:31 p.m. on 12/30/16 prior to the incident. RN #1 made no further nursing documentation to address the abuse allegation or an assessment for injury related to the abuse allegation.

3. Interview with Health Service Worker (HSW) #2 on 2/13/17 at 2:15 p.m. revealed RN #1 was aware of the abuse allegation during the evening shift of 12/30/16.

4. Interview with HSW #4 on 2/14/17 at 3:30 p.m. revealed RN #1 was aware of the abuse allegation during the evening shift of 12/30/16.

5. Review of the hospital investigation into this abuse allegation revealed RN #1 confirmed she was aware of the abuse allegation during the evening shift of 12/30/16.

6. The above findings were reviewed and discussed with the Chief Nursing Officer at 10:00 a.m. on 2/14/16 and she agreed with the findings.

WV 200 2017-3-006

C. Based on record review and staff interview it was determined the registered nurse failed to ensure weekly weights were recorded for one (1) of three (3) patients reviewed who had weekly weights ordered (patient #1). This failure creates the potential for an adverse impact on the health of all patients who require frequent weight monitoring.

Findings include:

1. Review of physician's orders for patient #1 revealed a 10/11/16 order for the patient to be weighed weekly. Review of the record revealed no weights were recorded for patient #1 between 10/11/16 and 1/5/17 when she was transferred to an outside medical facility for treatment.

2. The above finding was reviewed and discussed with the Chief Nursing Officer at 10:00 a.m. on 2/14/16 and she agreed with the finding.





WV 201 2017-3-007

D. Based on document review and staff interview it was determined the facility failed to ensure nursing staff supervised the care of all patients when in an outdoor setting for one (1) of four (4) records reviewed (patient #1). This failure has the potential for all patients to be unattended and therefore subject to environmental hazards and self-harm.

Findings include:

1. The facility self-reported an incident on 12/26/16 when Registered Nurse (RN) #1 and Health Service Worker (HSW) #1 took four (4) patients to an outdoor courtyard for fresh air and returned with only three (3) patients. A review of the Root Cause Analysis which the facility completed immediately following the incident revealed both staff admitted to leaving patient #1 unattended in the outdoor courtyard on 12/26/16.

2. The facility policy entitled "Patient location/Activity", last reviewed 1/4/16, revealed the procedure for taking patients off of their unit for activity. It stated, in part: "Form D will be taken to Off Unit Activities that include Fresh Air and Recreation Hall...As each patient leaves the activity site the responsible person will initial the appropriate section. A patient count will be done as patients enter the unit upon returning from an activity site."

3. HSW #1 was interviewed on 2/13/17 at about 11:21 a.m. and the above incident was discussed. She stated she was one of the staff members that left patient #1 in the outdoor courtyard when they returned to the unit. She also stated she mistakenly documented patient #1 returned to the unit with the group and that she miscounted the patients when they returned to the unit.

4. RN #1 was interviewed on 2/14/17 at about 11:00 a.m. and the above incident was discussed. She stated she went to the outdoor courtyard with HSW #1 and four (4) patients. She stated '[patient #1] got left behind' when they returned to the unit. It was not discovered until he was returned to the unit about twenty (20) minutes after they got back to the unit when a supervisor returned patient #1 to the unit unharmed. RN #1 stated she was not the staff designated to complete Form D but admitted as the RN she was responsible to evaluate and supervise patient #1's care, including outdoor trips.