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 May 10, 2017
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined the hospital failed to ensure a registered nurse supervised and evaluated the care of two (2) of two (2) patients reviewed who reported having sex (patients #2 and 6). This failure creates a potential for an adverse impact on the care and condition of all patients.

Findings include:

1. The abuse investigations for patients #2 and 6 regarding suspected sexual activity alleged to have occurred on 4/7/17 were reviewed. The files included a 4/20/17 statement from Health Service Worker (HSW) #2 indicating she reported to Registered Nurse (RN) #2 and RN #3 on 4/7/17 that patient #6 stated he had sex with patient #2 and patient #2 was also talking about sex. The statement indicated RN #2 stated patient #6 was lying and it never happened. The statement indicated RN #2 also stated patient #2 had a [DIAGNOSES REDACTED].

An additional statement in the file by HSW #3 indicated patient #2 was seen in the male hallway on 4/7/17 without her pants. The statement indicated HSW #3 and HSW #2 assisted the patient in putting her pants on in the bathroom by the nurse's station and the patient was noted to be talking about sex.

2. Interview was conducted with HSW #2 at 10:34 a.m. on 5/9/17. She confirmed she reported to RN #2 and RN #3 that patient #6 reported having sex with the new girl and he described patient #2. She stated patient #2 was seen in the male hallway without any pants. HSW #2 stated she and HSW #3 assisted the patient to put on her pants and stated patient #2 was talking about sex and continued to talk about sex after being taken back to the day area. She confirmed RN #2 and RN #3 failed to come out of the nurse's station to assess the patients.

3. The above noted investigation was reviewed and discussed on 5/9/17 at 1:34 p.m. with the Director of Nursing (DON) who investigated the sexual abuse/neglect allegations. She confirmed the HSW statements reflected the nurses failed to respond to the allegation of sexual activity and assess the patients per expectations.

The DON confirmed she failed to interview the nurses and did not substantiate abuse or neglect by staff. The DON did state that RN #2 had since been terminated for another case. The surveyor later confirmed RN #2 was terminated on 4/17/17. RN #3 was observed on duty on the C 2 Unit at 4:40 p.m. on 5/9/17.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, document review and staff interview it was determined the hospital failed to ensure allegations of suspected abuse/neglect were reported immediately per policy (see Tag A 145); and, the hospital failed to ensure the process for investigating suspected abuse/neglect of patients included witness interviews per policy (see Tag A 145).
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on document review, record review and staff interview it was determined the hospital failed to ensure allegations of suspected abuse/neglect of patients were reported immediately per policy for three (3) of ten (10) patients reviewed who had an allegation of abuse/neglect during hospitalization (patients #1, 2 and 6). This failure results in an increased risk for abuse/neglect of patients.

Findings include:

1. Review of investigation documentation related to an abuse/neglect allegation regarding patient #1 revealed the incident was alleged to have occurred on 4/4/17 and was not reported until 4/6/17. Review of the clinical record for patient #1 revealed the record reflected the mandatory Adult Protective Services (APS) report was completed 4/6/17. Statements provided by staff who were present during a medication pass were reviewed. Statements by two (2) staff members, one (1) undated and the other dated 4/19/17, described witnessing suspected drug diversion.

2. Anonymous interviews were conducted with Staff #2 at 1:32 p.m. on 5/8/17 and Staff #3 at 9:34 a.m. on 5/9/17. Both were interviewed in regard to the anonymous report of suspected drug diversion which involved patient #1 and Licensed Practical Nurse (LPN) #1. Both staff members stated they witnessed actions on the evening of 4/4/17 which led them to suspect LPN #1 diverted part of the patient's 8:00 p.m. dose of medications. Both staff members voiced awareness of their responsibility as mandatory reporters but stated they were not comfortable reporting the suspected diversion to supervisory nursing staff on duty. Both indicated they felt staff would not address the allegations or there would be repercussions for reporting.

3. The dual 5/5/17 investigations related to reports of sexual activity between patient #2 and patient #6 were reviewed. The investigation files indicated the alleged sexual contact was alleged to have occurred 4/7/17 but this was not reported and the APS report was not completed until 4/20/17. Review of a 4/20/17 written statement by Health Service Worker (HSW) #2 stated both patients were talking about having sex on 4/7/17 and this was reported to the nursing staff on duty on 4/7/17. Another staff statement in the file by HSW #3 indicated patient #2 was observed in the male hallway without her pants on 4/7/17.

Interview was conducted with HSW #2 on 5/10/17 at 10:34 a.m. The HSW confirmed the suspected sexual activity was reported to nursing staff on 4/7/17. The HSW stated registered nurse (RN) #2 told her that patient #6 tells lies and patient #2 has a [DIAGNOSES REDACTED]. She confirmed nursing staff failed to respond to the report and therefore the allegation was not reported on 4/7/17. The HSW confirmed she was a new employee with a hire date of 3/1/17. When the incident occurred on 4/7/17 she immediately reported to RN #2 and RN #3 who were the nurses on duty on the C 2 Unit at the time the allegation was made. She stated she was puzzled when the nurse told her it didn't happen and directed staff to tell the patient to stop talking about it. The HSW confirmed she now recognized she should go to the nursing supervisor if nursing staff on the Unit do not respond to patient needs.

Interview was conducted with HSW #3 on 5/10/17 at 3:10 p.m. She confirmed nursing staff on the C 2 Unit were made aware on 4/7/17 of the alleged sexual activity by patients #2 and 6.

4. The policy "Reporting and Investigating Abuse of Patients," effective date 2/93, was provided for review. The policy states in part: "Mandatory reporter is defined as medical professionals...mental health professionals...including those employed by DHHR...All employees, volunteers, student/interns of the hospital are considered mandatory reporters. Individuals who witness, have knowledge of patient abuse or have reason to believe abuse occurred shall immediately report to the RN and/or Nurse Manager assigned to the unit where the patient resides or to the Nurse Clinical Coordinator. The mandatory reporter will then complete the APS Mandatory Reporting Form and call the Centralized Intake Unit..."

5. The above findings were reviewed with the Director of Nursing Service at 1:25 p.m. on 5/9/17. She agreed with the findings and acknowledged staff failed to report the suspected drug diversion and sexual activity immediately as required.

B. Based on document review and staff interview it was determined the hospital failed to ensure the process for investigating abuse/neglect of patients included witness interviews per policy. This failure impacted ten (10) of ten (10) patient investigations reviewed (patients #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10) and increases the potential for patients to be abused.

Findings include:

1. Review of the 4/24/17 investigation report to the Chief Executive Officer (CEO) regarding alleged abuse of patient #1 revealed the only interview conducted was with the alleged perpetrator. There were no interviews conducted by the investigator with staff or patient witnesses.

2. Review of the 5/5/17 investigation report to the CEO regarding alleged abuse of patient #2 revealed no staff or patient witness interviews were conducted by the investigator.

3. Review of the 8/11/16 investigation report to the CEO regarding alleged abuse of patient #3 revealed no staff or patient witness interviews were conducted by the investigator.

4. Review of the 2/1/17 investigation report to the CEO regarding alleged abuse of patient #4 revealed no staff or patient witness interviews were conducted by the investigator.

5. Review of the 4/24/17 investigation report to the CEO regarding alleged abuse of patient #5 revealed no staff or patient witness interviews were conducted by the investigator.

6. Review of the 5/5/17 investigation report to the CEO regarding alleged abuse of patient #6 revealed no staff or patient witness interviews were conducted by the investigator.

7. Review of the 5/5/17 investigation report to the CEO regarding alleged abuse of patient #7 revealed no staff or patient witness interviews were conducted by investigator.

8. Review of the 4/28/17 investigation report to the CEO regarding alleged abuse of patient #8 revealed no staff or patient witness interviews were conducted by the investigator.

9. Review of the 4/28/17 investigation report to the CEO regarding alleged abuse of patient #9 revealed no staff or patient witness interviews were conducted by the investigator.

10. Review of the 4/28/17 investigation report to the CEO regarding alleged abuse of patient #10 revealed no staff or patient witness interviews were conducted by the investigator.

11. The policy "Reporting and Investigating Abuse of Patients," effective date 2/1993, was provided for review. The policy states in part, under Investigation: "...7. Upon assignment, the investigator will then complete the investigation which will include interviewing staff witnesses, patient witnesses, the alleged victim(s), and the alleged perpetrator(s)..."

12. Interview was conducted with the Director of Nursing (DON) at 1:25 p.m. on 5/9/17. The above findings were reviewed and discussed. The DON acknowledged she had been serving as an abuse investigator for the past several months. When the process for investigation in the policy was read, she acknowledged she was not doing it all. The DON stated she was not aware staff and patient witness interviews were expected to be completed as part of the abuse investigation.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on document review and staff interview it was determined the hospital's governing body failed to ensure the program involves participation of all hospital departments and services, including hospital administration. This failure impacted five (5) of five (5) meetings reviewed for 2017 and has the potential to negatively impact the quality of services provided.

Findings include:

1. The Medical Staff Rules and Regulations, last reviewed 10/16, were provided for review. Review at '11.4-1 Continuous Quality Improvement (CQI) Committee', revealed it states, in part: "The Continuous Quality Improvement Committee shall include, but not be limited to the following: Clinical Director, (EX-officio), CEO (ex-officio), Medical Staff member, Deputy Clinical Director, Chief Compliance Officer, Director of Nursing, Co-Directors of Social Work, Director of Psychology, and Clinical Services Director."

2. The 2017 CQI Committee meeting minutes were reviewed. The Committee met on 1/31, 2/28, 3/8, 3/28 and 5/2/17. The minutes reflected neither the Chief Executive Officer (CEO) nor the Assistant CEO attended any of the committee meetings.

3. Interview was conducted with the CEO on 5/10/17 at 9:47 a.m. The above noted meeting minutes were reviewed and discussed. He stated he had attended two (2) of the five (5) meetings. He stated he usually comes in late and acknowledged he wasn't noted as present in the minutes. The CEO stated he will ensure this is corrected.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on document review and staff interview it was determined the Director of Nursing failed to be responsible for essential duties and responsibilities related to safe and competent nursing care (see Tag A 386); and, the hospital failed to ensure the registered nurse supervised and evaluated care for patients who reported sexual activity (see Tag A 395).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and staff interview it was determined the Director of Nursing failed to be responsible for essential duties and responsibilities related to safe and competent nursing care. This failure involved two (2) of two (2) patients reviewed who were reported to have engaged in sexual activity and one (1) of one (1) patients reviewed who was reported to have had medications diverted by nursing staff (patients #1, 2 and 6). All three (3) of the subsequent investigations included statements of wrongdoing by nursing staff. This failure creates the potential for an adverse impact on the quality of care for all patients.

Findings include:

1. Review of hospital abuse/neglect investigation reports for patients #2 and 6 revealed sexual activity was alleged to have occurred on 4/7/17 but not reported until 4/20/17. Review of the statements in the investigation files for these patients revealed a 4/20/17 statement from Health Service Worker (HSW) #2. The statement indicated she reported the suspected sexual activity and the patients' reports of sexual activity to the nursing staff on duty on 4/7/17, RN #2 and RN #3, as soon as she became aware of the incident.

The HSW statement went on to say that RN #2 stated patient #6 told lies and patient #2 had a [DIAGNOSES REDACTED]. The statement indicated neither nurse assessed the patients.

The file included another 4/20/17 statement from HSW #3 which indicated patient #2 was found in the male hallway on 4/7/17 and was not wearing pants. Review of the investigation files revealed neither file had statements from RN #2 or RN #3.

Review of the investigation files for patient #2 and 6 indicated no staff interviews were conducted.

2. At 10:34 a.m. on 5/9/17 HSW #2 was interviewed. At 3:10 p.m. on 5/10/17 HSW #3 was interviewed. Both confirmed the information in their earlier statements which indicated nursing staff was made aware of the allegation of sexual activity between patients on 4/7/17 but did not respond. Both stated they had not been interviewed in the course of the hospital investigation.

3. The above noted investigation files and the 4/20/17 statements by HSW #2 and 3 were reviewed and discussed at 1:34 p.m. on 5/9/17 with the Director of Nursing (DON). She confirmed she completed the hospital's investigations of this incident for both patients. She acknowledged she failed to obtain statements or interview either of the nurses referenced in the statement by the HSW. The DON acknowledged the HSW's statement indicated that nursing staff did not provide care per expectations. She also indicated she had not followed up in any way related to the performance of the nursing staff. She did state that RN #2 had been terminated recently for another case of failure to report but confirmed RN #3 was still employed.

4. Review of the abuse/neglect investigation report for patient #1 revealed drug diversion was alleged to have occurred on 4/4/17 but not reported until 4/6/17. Review of the signed statements in the investigation file for this patient revealed an undated statement and an 4/19/17 statement from Staff #2 and Staff #3 which indicated drug diversion was suspected by the staff.

Staff #2 and Staff #3 were interviewed individually in the afternoon of 5/8/17 and morning of 5/9/17. Both confirmed suspicions of drug diversion and indicated they did not feel comfortable reporting to the supervisory nursing staff who were on duty on 4/4/17. The staff noted fears the issue would be covered up and would not remain confidential. They verbalized fear they may be subjected to harassment and/or repercussions. Both staff stated they had not been interviewed in the course of the hospital investigation.

5. The above noted investigation of patient #1 was discussed with the DON at 1:34 p.m. on 5/9/17. She confirmed she completed this investigation without speaking to any staff witnesses.

6. The current job description for the DON was provided. Review of the 4/6/11 job description revealed it states, in part: "The major function of the position of Chief Nurse Officer is to serve as the nursing executive of the hospital and create an environment that ensures safe and competent nursing care..." Under 'Essential Duties and Responsibilities' it states, in part: "Leads, coaches, develops and recognizes staff to maximize performance...Continuing education of staff on the established guidelines for reporting significant medical errors or unanticipated outcomes and any issue relate to reporting abuse and/or neglect."