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.

HIGHLAND-CLARKSBURG HOSPITAL INC 3 HOSPITAL PLAZA CLARKSBURG, WV 26301 April 10, 2014
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, video review and staff interview it was determined the hospital failed to provide care in a safe setting by not ensuring that all patients who are placed on a one (1) staff member assigned to one (1) patient supervision (1:1) have this care provided as ordered. This deficient practice was found in one (1) of one (1) patients in the children's unit (1 Central) who were ordered a 1:1 staffing on 3/21/14 (patient #1). Failure to perform 1:1 supervision as ordered can result in a possible unsafe care setting which could lead to patient/staff injury with adverse outcomes.
Findings include:

Review of the medical record for patient #1 revealed the patient was a six (6) year old female patient that was admitted on [DATE] and discharged on [DATE]. Through out the patients hospitalization the physician ordered the patient to be supervised by a one (1) to one (1) staffing.

An interview was conducted with the Director of Quality Assurance Performance Improvement (QAPI) on 4/9/14 at 1440. The Director was asked to define a 1:1 status and she replied," staff is to be arm's length away from the patient and to maintain constant visual contact." During this interview the Director provided the survey team, for review, portions of video footage from security cameras located on unit 1 Central, dated 3/21/14, during the time when the incident occurred. The following is a synopsis of the review of this video feed:
The footage from 1421 hrs revealed both patients standing at the nurse 's station, with all staff noted to be within the station, and no one-to-one observation in progress. The footage from 1436 hrs revealed both patients on the floor together, then standing up together in front of the nurse's station. Again, all nursing staff were observed within the station, with no one-to-one observation in progress. The footage from 1442 hrs revealed both patients standing in the hallway, hugging and kissing, with no staff nearby, and no one-to-one observation in progress. The footage at 1525 hrs revealed Patients #1, #2, and a third, unidentified patient, in the dining room , with Patients #1 and #2 making repeated physical contact, no staff present, and no one-to-one observation in progress.
The Director of QAPI at the time of the viewing agreed the patient had not been on 1:1 supervision for over an hour.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review, video review and staff interview it was determined that nursing failed to supervise, assign and ensure that care is provided as ordered for all patients who are placed on a one (1) staff member assigned to one (1) patient supervision (1:1). Additionally, nursing failed to monitor/check Behavior Health Technicians (BHT) documentation of patient care for accuracy and adherence to patient assignments and physician orders. This deficient practice was found in one (1) of one (1) patients in the children's unit (1 Central) who were ordered a 1:1 staffing on 3/21/14 (patient #1). When nursing fails to supervise, clearly assign and monitor Behavioral Health Technicians' (BHT), performance can result in patients not receiving care as ordered leading to possible patient/staff injury with adverse outcomes.

Findings include:

Review of the medical record for patient #1 revealed the patient was a six (6) year old female patient who was admitted on 3/14/14 and discharged on [DATE]. Throughout the patient's hospitalization the physician ordered the patient to be supervised by one (1) staff member to one (1) patient staffing.

An interview was conducted with the Director of Quality Assurance Performance Improvement (QAPI) on 4/9/14 at 1440. The Director was asked to define a 1:1 status and she replied,"staff is to be arm's length away from the patient and to maintain constant visual contact." During this interview the Director provided the survey team, for review, portions of video footage from security cameras located on unit 1 Central, dated 3/21/14, during the time when the incident occurred. Also reviewed at this time were documents from Patient #1's and Patient #2's medical records entitled "Observation Records" dated 3/21/14.
The following are the findings of the video review with comparison to staff documentation on the observation records:
The footage from 1421 hrs revealed both patients standing at the nurse ' station, with all staff noted to be within the station, and no one-to-one observation in progress. At this same time the Observation sheets noted Patient #1's location as " Dining Room " and Patient #2 location as "Gym/Outside." The footage from 1436 hrs revealed both patients on the floor together, then standing up together in front of the nurse 's station. Again, all nursing staff were observed within the station, with no one-to-one observation in progress. The Observation sheets noted at this time the location of both patients to be "Dining room/writing." The footage from 1442 hrs revealed both patients standing in the hallway, hugging and kissing, with no staff nearby, and no one-to-one observation in progress. Again, at this time nursing documented on the observation sheet was that both patients were in the "Dining room/writing." The footage at 1525 hrs revealed Patients #1, #2, and a third, unidentified patient, in the dining room, with Patients #1 and #2 making repeated physical contact, no staff present, and no one-to-one observation in progress. The Observation Records of both children noted their location as Dining room/attending Group at this time.
The Director of QAPI at the time of the viewing agreed nursing had not provided the 1:1 care. Also, she concurred the documentation on the observation sheets did not match what was on the video.
A request was made by the survey team for the staff assignment sheet for 3/21/14. The Director of Quality Assurance on 3/8/14 at 1100 hrs presented a form entitled the "daily assignment sheet." The sheet did not document the patient staff assignments. Also, there were no staff assigned to breaks that included coverage for the 1:1 patient during their breaks or lunch. The Director agreed the form was incomplete and they needed to develop a new form to correct this issue which might prevent a reoccurrence of the incident involving patient #1 on 3/21/14.

Additionally, the Director agreed that on 3/21/4 there were three (3) patients on 1 Central and one (1) patient on the Intellectually Delayed Developmentally (IDD) side of the unit. The staffing for that day was one (1) registered nurse and three (3) Behavioral Health Technicians (BHT) for a total of four (4) patients.

Observations made on the children's unit (1 Central) on 4/9/14 at 0915 hrs revealed the unit had one (1) patient that was on a 1:1 patient assignment. Upon request the charge nurse provided the staff/patient assignment sheet for that day. Review of this sheet revealed the staff to patient assignment section had been completed however, the section for staff break/lunch assignment was blank.

The charge nurse reviewed the above assignment sheet on 4/9/14 at 0930 hrs and agreed the sections for staff assignments for breaks and lunch were not filled out.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on record review and staff interview, it was determined the facility failed to follow its policy for providing discharge instructions, ensuring continuation of medications, and documenting the patient's destination and mode of transportation for one (1) of 3 (three) discharged patients (Patient #1). This has the potential to adversely affect the safety and continuity of care of all patients discharged from this facility.

Findings include:

1. The facility's policy entitled "Discharge Process", approved 7/31/13, was reviewed on 4/7/14. It states, in part, under the heading "Procedure, 1. Planned Discharge, 1.2 Nursing staff will assist the patient in: 5. Understanding discharge instructions, 1.3 Nursing staff will document the discharge on the discharge note. This documentation will include: 3. The patient's destination and mode of transportation upon discharge, 5. The patient's method for obtaining medication (if applicable)".

2. Patient #1's medical record was reviewed on 4/7/14. The document entitled "Discharge Instruction Sheet", dated 3/24/14 revealed no entry indicating prescriptions were or were not provided to the patient/guardian at discharge. It revealed no entry under the heading "Living arrangements following discharge/address". It revealed no signatures or dates by the patient, guardian, physician, or discharging nurse indicating instructions had been provided and reviewed. The document entitled "Nursing Progress Note", dated 3/24/14 revealed, in part, the entry at 1515 "Patient was transported off of unit with security", with no mode of transportation indicated.

3. Further review of Patient #1's medical record revealed a document entitled "Patient's Progress Note", dated 3/25/14 timed at 1410, signed by the Director of Nurse Manager-Children's unit. It revealed, in part, the entry "Pt.'s mother called me and was very upset...The mother stated she did not have d/c (discharge) instructions, a dx (diagnosis), a school return excuse, and that the pt.'s meds. had not been called in to the pharmacy...I spoke with the d/c nurse, was told that the Dr. said she'd mail the d/c instructions. The d/c nurse then spoke with the doctor about calling in the scripts (prescriptions). The doctor called in the scripts to the pharmacy of choice. The doctor agreed to call the pt.'s mom and to mail the d/c instructions". An entry made on this same note at 1525 revealed, in part, the entry "Pt's mom was notified by this nurse that the pt's meds. were called in and that the Dr. would mail the d/c instructions".

4. An interview was conducted with the Director of Quality Assurance Performance Improvement on 4/8/14 at 1345, during which Patient #1's discharge documentation, as noted above, was reviewed. She agreed the discharge instruction sheet contained no documentation of prescriptions given, destination or mode of transportation, and no signatures and dates indicating discharge instructions had been provided and explained to the patient's guardian per facility policy.