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.
| FAIRMONT REGIONAL MEDICAL CENTER | 1325 LOCUST AVENUE FAIRMONT, WV 26554 | Sept. 21, 2016 |
| VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING | Tag No: A0144 | |
| WV 590 2016-3-122 Based on reviews of medical records and other documents and interviews with staff, it was determined the hospital failed to ensure care was provided in a safe setting for three (3) of twelve (12) patients reviewed (patients #6, #11 and #12). This has the potential for all patients to not have personal safety provided for at all times. Findings include: 1. The Chief Nursing Officer provided documents for review for a substantiated allegation of abuse by a staff Certified Nurse Assistant (CNA) to patient #6. Review of the documents relative to the incident revealed the staff member allegedly physically assaulted the patient by twisting the patient's arm and pinching him during the evening shift on 8/27/16. The hospital's investigation determined the CNA did physically abuse the patient as alleged and he was then terminated from employment. Review of the hospital's investigation included documents relative to a substantiated allegation of neglect in the care of patient #12 on 8/6/16 for which he received disciplinary action. Included in the hospital's investigation were interviews of various staff members who had observed the care provided in the weeks prior to the 8/27/16 incident. One (1) Licensed Practical Nurse (LPN) reported that she had witnessed the CNA about two (2) weeks prior to 8/27/16 interacting with patient #11 in the hallway. She stated the CNA "puffed chest out and shoved himself up against (the patient). Then grabbed arms or wrist to hold down arms because (the patient) was pointing his finger at him". It was documented she stated she had not reported it at the time "because he (the patient) did not get hurt". The Director of Clinical Services Behavioral Health was interviewed by telephone on 9/22/16 at 8:50 a.m. She stated that after the first incident on 8/6/16 she had instructed the Registered Nurses (RNs) to "watch for any kind of behavior" of the CNA. She concurred the incident with patient #11 should have been reported immediately when witnessed in accordance with the hospital's expectation for reporting any suspected abuse. 2. Review of the medical record for patient #6 revealed an LPN was assigned to sit 1:1 (one on one) with the patient during the evening shift 3:00 p.m. to 11:00 p.m. on 8/26/16. The LPN documented at 11:16 p.m. "Patient combative, hitting and kicking. Had to be physically held in bed for all the hours not sleeping". She noted the patient had slept a total of 1.25 hours during the shift. There was no physician order for the patient to be physically held. The RN documented at 11:05 p.m.: "Restless and anxious. Tries to climb out of bed. Remains 1:1." The RN did not document any physical hold of the patient during the shift. The record was reviewed with the Clinical Supervisor of Behavioral Medicine on 9/21/16 at 9:30 a.m. He concurred the documentation reflected a potential for inappropriate care by the LPN and inadequate RN supervision of care to ensure care is provided safely and in accordance with physician orders and hospital policies. |
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| VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT | Tag No: A0145 | |
| WV 590 2016-3-122 Based on reviews of medical records and other documents and interviews with staff, it was determined the hospital failed to ensure three (3) of twelve (12) patients reviewed were free from abuse or neglect (patients #6, #11 and #12). This has the potential for all patients to have their rights to personal safety be violated. Findings include: 1. The Chief Nursing Officer provided documents for review for a substantiated allegation of abuse by a staff Certified Nurse Assistant (CNA) to patient #6. Review of the documents relative to the incident revealed the staff member allegedly physically assaulted the patient by twisting the patient's arm and pinching him during the evening shift on 8/27/16. The hospital's investigation determined the CNA did physically abuse the patient as alleged and he was then terminated from employment. Review of the hospital's investigation included documents relative to a substantiated allegation of neglect in the care of patient #12 on 8/6/16 for which he received disciplinary action. Included in the hospital's investigation were interviews of various staff members who had observed the care provided in the weeks prior to the 8/27/16 incident. One (1) Licensed Practical Nurse (LPN) reported that she had witnessed the CNA about two (2) weeks prior to 8/27/16 interacting with patient #11 in the hallway. She stated the CNA "puffed chest out and shoved himself up against (the patient). Then grabbed arms or wrist to hold down arms because (the patient) was pointing his finger at him". It was documented she stated she had not reported it at the time "because he (the patient) did not get hurt." The Director of Clinical Services Behavioral Health was interviewed by telephone on 9/22/16 at 8:50 a.m. She stated that after the first incident on 8/6/16 she had instructed the Registered Nurses (RNs) to "watch for any kind of behavior" of the CNA. She concurred the incident with patient #11 should have been reported immediately when witnessed in accordance with the hospital's expectation for reporting any suspected abuse. 2. Review of the medical record for patient #6 revealed an LPN was assigned to sit 1:1 (one on one) with the patient during the evening shift 3:00 p.m. to 11:00 p.m. on 8/26/16. The LPN documented at 11:16 p.m.: "Patient combative, hitting and kicking. Had to be physically held in bed for all the hours not sleeping". She noted the patient had slept a total of 1.25 hours during the shift. There was no physician order for the patient to be physically held. The RN documented at 11:05 p.m.: "Restless and anxious. Tries to climb out of bed. Remains 1:1". The RN did not document any physical hold of the patient during the shift. The record was reviewed with the Clinical Supervisor of Behavioral Medicine on 9/21/16 at 9:30 a.m. He concurred the documentation reflected a potential for inappropriate care by the LPN and inadequate RN supervision of care to ensure care is provided safely and in accordance with physician orders and hospital policies. |
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| VIOLATION: PATIENT SAFETY | Tag No: A0286 | |
| WV 590 2016-3-122 Based on reviews of medical records and other documents and interviews with staff, it was determined the hospital failed to implement preventive actions and mechanisms that include review of policies for adequacy and education throughout the hospital of the expectation of safety. This has the potential for patients to receive care in an unsafe setting. Findings include: 1. Review of the policy "Abuse", last reviewed 5/28/15, reveals the policy states: "Procedure for suspected patient abuse by staff: 1. Incidents of abuse, neglect, or harassment or suspicions of the above, shall be reported immediately to the nurse manager or off-shift supervisor. 2. An occurrence report will also be completed by the staff member involved with the report. 3. The patient will be assessed by an RN (Registered Nurse), whether the nurse manager or the off-shift supervisor. 4. Once the allegation of abuse is reported, the manager or off-shift supervisor will meet with the Vice-Present of Patient Services and Human Resources to discuss allegations and take appropriate action as warranted. 5. To insure that abuse, neglect or harassment of patient does not occur, the staff person involved will immediately be removed from care of the patient." The policy was reviewed with the Program Director of the Behavioral Health Unit (BHU) and the Clinical Supervisor of the BHU on 9/21/16 at 9:30 a.m. They concurred the policy failed to ensure how all patients will be kept safe during an investigation of an allegation of abuse or neglect as the policy states the staff person involved will be removed from care of "the" patient and not all patients while the investigation occurs. 2. The Chief Nursing Officer provided documents for review for a substantiated allegation of abuse by a staff member to a patient. Review of the documents relative to the incident revealed the staff member allegedly physically assaulted the patient by twisting the patient's arm and pinching him during the evening shift on 8/27/16. The Program Director and the Clinical Supervisor of the BHU stated during the interview on 9/21/16 at 9:30 a.m. the staff on the two (2) Behavioral Health Units (2B and 4B) received re-education about abuse and neglect during staff meetings conducted on 9/6 and 9/7/16. During a second interview on 9/21/16 at 2:00 p.m., the Program Director stated all staff received the information presented in the meetings via email if they were not present during the meeting. She stated only the staff on 2B and 4B were sent the email. The Director of Medical/Surgical/Telemetry/Oncology was interviewed on 9/21/16 at 1:00 p.m. She stated that the staff members of her units have not been provided re-education relative to abuse and neglect since the alleged incident occurred on 8/27/16. |
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| VIOLATION: RN SUPERVISION OF NURSING CARE | Tag No: A0395 | |
| WV 590 2016-3-122 Based on reviews of medical records and other documents and interviews with staff, it was determined the hospital failed to ensure adequate Registered Nurse supervision of care occurred for three (3) of twelve (12) patients reviewed (patients #6, #11 and #12). This has the potential for patients to receive care in an unsafe setting. Findings include: 1. The Chief Nursing Officer provided documents for review for a substantiated allegation of abuse by a staff Certified Nurse Assistant (CNA) to patient #6. Review of the documents relative to the incident revealed the staff member allegedly physically assaulted the patient by twisting the patient's arm and pinching him during the evening shift on 8/27/16. The hospital's investigation determined the CNA did physically abuse the patient as alleged and he was then terminated from employment. Review of the hospital's investigation included documents relative to a substantiated allegation of neglect in the care of patient #12 on 8/6/16 for which the CNA received disciplinary action. Included in the hospital's investigation were interviews of various staff members who had observed the care provided in the weeks prior to the 8/27/16 incident. One (1) Licensed Practical Nurse (LPN) reported that she had witnessed the CNA about two (2) weeks prior to 8/27/16 interacting with patient #11 in the hallway. She stated the CNA "puffed chest out and shoved himself up against (the patient). Then grabbed arms or wrist to hold down arms because (the patient) was pointing his finger at him." It was documented she stated she had not reported it at the time "because he (the patient) did not get hurt". The Director of Clinical Services Behavioral Health was interviewed by telephone on 9/22/16 at 8:50 a.m. She stated that after the first incident on 8/6/16 she had instructed the Registered Nurses (RNs) to "watch for any kind of behavior" of the CNA. She concurred the incident with patient #11 should have been reported to an RN immediately when witnessed and the CNA should have been monitored more closely by all RNs involved in supervision of care. 2. Review of the medical record for patient #6 revealed an LPN was assigned to sit 1:1 (one on one) with the patient during the evening shift 3:00 p.m. to 11:00 p.m. on 8/26/16. The LPN documented at 11:16 p.m.: "Patient combative, hitting and kicking. Had to be physically held in bed for all the hours not sleeping". She noted the patient had slept a total of 1.25 hours during the shift. There was no physician order for the patient to be physically held. The RN documented at 11:05 p.m.: "Restless and anxious. Tries to climb out of bed. Remains 1:1." The RN did not document any physical hold of the patient during the shift. The record was reviewed with the Clinical Supervisor of Behavioral Medicine on 9/21/16 at 9:30 a.m. He concurred the documentation reflected a potential for inappropriate care by the LPN and inadequate RN supervision of care of the patient. |
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