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 May 22, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on record review, policy review and interviews it was determined the hospital failed to ensure care was given in a safe setting and that the patients who were diagnosed with suicidal ideation in the Emergency Department (ED) were not monitored one (1) on one (1) in six (6) out of eight (8) patients diagnosed with suicidal ideations (patients #1, #2, #4, #5, #6 and #19). This failure has the potential for all patients who present to the ED with thoughts of killing themselves to cause self-harm while being treated in the ED. (See tag A 144).

A. An immediate jeopardy to the ED for failure to monitor patients one (1) on one (1) who were diagnosed with suicidal ideations was called on 05/22/19 at 12:35 p.m.

B. Harm or Potential Harm: The patients (patients #1, #2, #4, #5 #6, and #19) were diagnosed with suicidal ideations with a plan to commit suicide. An order for continuous monitoring was placed in the computer but no one (1) on one (1) care was provided by the ED staff.

C. Immediacy: On 5/22/19 at 9:00 a.m. observation in the ED noted a patient with suicidal ideations was admitted to emergency room nine (9) on 05/22/19 at 3:22 a.m. and placed on suicide precautions. No one (1) on one (1) monitoring was observed. An interview was conducted with Registered Nurse (RN) #1 on 05/22/19 at 9:20 a.m. When asked why patient #19 did not have a sitter to ensure continuous monitoring she stated in part: "I didn't know he was on constant observation and I assume the aide got report and would know." When asked if she was aware that the patient was a suicidal ideation patient she stated in part: "Yes, I knew. He's well known to us." When asked if she could explain the emergency room 's policy on suicidal ideation patients she stated in part: "Yes, they all have to have someone with them in the room."

An immediate plan of correction to abate the I.J. was received and sent to the State Agency Program Directors. It was accepted and the facility abated the I.J. on 05/22/19 at 2:45 p.m.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, policy review and interviews it was determined the facility failed to document care on one (1) out of four (4) patients (patient #20) who was in restraints in the Emergency Department (ED). This failure has the potential to affect all patients who are restrained in the ED.

Findings include:

1. Review of the medical record for patient #20 revealed no documentation of the care of the patient after restraints were applied on 3/8/19 at 07:04 until patient was transferred to another hospital on [DATE] at 1:38 p.m., including continued need for restraints.

2. Review of the policy titled Seclusion and Restraints with a last review date of 3/2018 states in part: "Documentation about seclusion or restraints will include: Assistance provided to the patient to help him/her meet the behavior criteria for discontinuation of seclusion or restraint. Continuous monitoring..."

3. An interview was conducted with the ED Manager on 5/22/19 at approximately 9:45 a.m. and she concurred restraint documentation had not been completed on patient #20.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on document review, medical record review and interviews it was revealed the hospital failed to collect data and monitor patients who were ordered one (1) to one (1) (1:1) continuous monitoring in its Quality Assessment/Performance Improvement program (QA/PI). This failure has the potential to affect all patients who are included in high risk and problem prone areas of care.

Findings include:

1. Review of the last six (6) months of QA/PI meeting minutes revealed there were no reports on patients who had been ordered 1:1 continuous monitoring.

2. Review of medical records for six (6) of eight (8) patients (patients #1, #2, #4, #5, #6 and #19) in the Emergency Department (ED) who had a diagnosis of suicidal ideation and ordered 1:1 continuous monitoring revealed documentation was not completed.

3. An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/19 at 9:35 a.m. and she concurred with the above findings.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review, observation, policy review and interviews it was determined the Director of the Emergency Department (ED) failed to ensure supervision of care on patients who were diagnosed with suicidal ideation in the ED were monitored one (1) on one (1) in six (6) out of eight (8) patients diagnosed with suicidal ideations (patients #1, #2, #4, #5, #6 and #19). This failure has the potential for all patients who present to the ED to receive unsupervised care by a Registered Nurse (RN) that could lead to the death of a patient. (See tag A 395).

A. An immediate jeopardy to the ED for failure to monitor patients one (1) on one (1) who were diagnosed with suicidal ideations was called on 05/22/19 at 11:35 a.m.

B. Harm or Potential Harm: The patients (patients #1, #2, #4, #5, #6 and #19) were diagnosed with suicidal ideations with a plan to commit suicide. An order for continuous monitoring was placed in the computer. No one (1) on one (1) care was provided by the emergency room staff.

C. Immediacy: On 5/22/19 at 9:00 a.m. observation in the ED noted a patient with suicidal ideations was admitted to emergency room nine (9) on 05/22/19 at 3:22 a.m. and placed on suicide precautions. No one (1) on one (1) monitoring was observed. An interview was conducted with RN #1 on 05/22/19 at 9:20 a.m. When asked why patient #19 did not have a sitter to ensure continuous monitoring she stated in part, "I didn't know he was on constant observation and I assume the aide got report and would know." When asked if she was aware that the patient was a suicidal ideation patient she stated in part, "Yes, I knew. He's well known to us." When asked if she could explain the emergency room 's policy on suicidal ideation patients she stated in part, "Yes, they all have to have someone with them in the room."

An immediate plan of correction was received and sent to the State Agency Program Directors. It was accepted and the facility abated on 05/22/19 at 2:45 p.m.
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
Based on observation and staff interviews it was determined the hospital failed to ensure Emergency Medical Treatment and Labor Act (EMTALA) signage was posted in a conspicuous place that is to be noticed by individuals entering the emergency department (ED). This failure has the potential for all patients who need care and cannot afford it to leave the hospital and seek life saving care at another facility that would increase their time to receive a medical screening.

1. A tour of the ED waiting room was conducted on 05/20/19 at 9:30 a.m. with the Clinical Manager of the ED. No signage was noted in the waiting room or on the exterior of the hospital by the ED doors.

2. An interview was conducted during the tour with the ED Clinical Manager and she concurred the signage was missing.

3. An interview was conducted on 05/20/19 at 10:00 a.m. with the Chief Nursing Officer (CNO). When told there was no EMTALA signage in the ED waiting room or on the exterior of the ED she stated in part, "They must've not put it back up after the remodel." After checking with the Facility Manager she noted the signage had not been up since the end of March to the beginning of April when the painter completed his job.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on record review, policy review, observation and interviews it was revealed a patient in the Emergency Department (ED) with a diagnosis of suicidal ideation (patient #19) was not receiving one (1) to one (1) (1:1) continuous monitoring as requried by hospital policy. This failure has the potential to affect all patients in the ED with a diagnosis of suicidal ideation as no continuous supervision allows the patient the opportunity to commit suicide.

Findings include:

1. A review of the medical record for patient #19 revealed there was no documentation of 1:1 continuous monitoring as required by hospital policy.

2. A review of the hospital policy titled Suicide Prevention with a last review date of 6/2017 states in part: "All patients on suicide precautions that reside on an unlocked unit will require 1:1 observation..."

3. Observation of patient #19 on 5/22/19 at approximately 9:10 a.m. in ED bed #9 revealed no hospital personnel at the bedside.

4. An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/19 at approximately 9:35 a.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on document review, observation, policy review and interviews it was determined the hospital failed to provide the correct phone number and address on how to submit a grievance to the State Agency on three (3) of three (3) documents. This failure has the potential to affect all patients who may want or need to notify the State Agency of a complaint or grievance.

Findings include:

1. Review of the admission packet booklet titled Patient Guide revealed the information on how to submit a complaint to the State Agency on page five (5) contained the wrong agency name, address and phone number.

2. Review of the hospital policy titled Patient Rights/Responsibilities with a last revised date of 6/2018 stated in part: "You may contact the West Virginia State Health Department Office of Health Facility Licensure and Certification Safety (304) 588-0050..."

3. Review of the hospital policy titled Patient Complaint/Grievance with a last revision date of 8/2016 stated in part: "The patient or representative is notified of his/her right to lodge a grievance with the State Agency or the Joint Commission via publication in the Patient Handbook..."

4. Observation of the framed Patient Rights and Responsibilities poster on the wall in the first floor hallway on 5/21/19 at approximately 8:00 a.m. revealed the phone number listed for submitting a complaint to the State Agency was (304) 588-0050.

5. An interview was conducted with the Chief Nursing Officer (CNO) on 5/21/19 at approximately 1:20 p.m. and she concurred with the above findings.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, observation, policy review and interviews it was determined the hospital failed to ensure care was given in a safe setting and that the patients who were diagnosed with suicidal ideation in the Emergency Department (ED) were monitored one (1) on one (1) in six (6) out of eight (8) patients diagnosed with suicidal ideations (patients #1, #2, #4, #5, #6 and #19). This failure has the potential for all patients who present to the ED with thoughts of killing themselves to cause self-harm while being treated in the ED.

1. Review of the medical record for patient #1 revealed a twenty-four (24) year old male who (MDS) dated [DATE] at 4:11 a.m. with complaints of wanting to kill himself by hanging. A medical screening was completed on 3/21/19 with a diagnosis of acute suicidal ideations and acute major depressive disorder with current active episode. An order for continuous monitoring was ordered. No documentation of continuous monitoring was noted in the medical record.

2. Review of the medical record for patient #2 revealed a thirty-one (31) year old male who (MDS) dated [DATE] at 5:35 a.m. with complaints of suicidal ideations with a plan to jump off a bridge to commit suicide. A medical screening was conducted on 03/21/19 at 4:15 a.m. A differential diagnosis of suicidal ideations, illicit drug use and depression was given and suicide precautions were ordered. No documentation of continuous monitoring was noted in the medical record.

3. Review of the medical record for patient #4 revealed a fourteen (14) year old female who (MDS) dated [DATE] at 8:17 p.m. with complaints of suicidal thoughts with a plan to cut herself and leave a note. A medical screening was completed on 03/21/19 at 8:19 p.m. A differential diagnosis of suicidal ideations and depression was given. The patient was placed on suicide precautions. No documentation of continuous monitoring was noted in the medical record.

4. Review of the medical record for patient #5 revealed a twenty-seven (27) year old male who (MDS) dated [DATE] at 9:19 p.m. with complaints of depression. A medical screening was completed on 4/22/19 at 9:23 p.m. A differential diagnosis of depression and detox from multiple substances was made. An order was placed for continuous monitoring. No documentation of continuous monitoring was noted in the medical record.

5. Review of the medical record for patient #6 revealed a fifty-three (53) year old male who (MDS) dated [DATE] at 11:18 p.m. with complaints of needing to detox and drinking liquid laundry detergent in a Gatorade bottle. A medical screening was completed on 04/22/19 at 11:20. A differential diagnosis was made of alcohol abuse, substance abuse disorder and depression. Suicide precautions were ordered. No documentation of continuous monitoring was noted in the medical record.

6. Review of the medical record for patient #19 revealed a sixty-three (63) year old male who (MDS) dated [DATE] at 3:22 a.m. with complaints of depression and suicidal thoughts with a plan to jump off a bridge. A medical screening was completed on 05/22/19 at 3:33 a.m. A differential diagnosis of suicidal ideations was made and an order was placed for continuous monitoring. No documentation of continuous monitoring was noted in the medical record.

7. Observation of the ED on 05/22/19 at 9:00 a.m. revealed an ED board patient #19 admitted with suicidal ideations. No ED staff was observed in the patient's room.

8. Review of the policy titled Suicide Prevention with a last review date of 06/2017 states in part: "All patients on suicide precautions that reside on an unlocked unit will require 1:1 observation."

9. An interview was conducted with Medical Assistant #1 on 05/22/19 at 9:15 a.m. When asked if she was to monitor patient #19 she stated in part, "I didn't know. I didn't get report this morning so I started cleaning up after night shift." When asked if the Registered Nurse (RN) caring for the patient had asked her to sit with the patient she stated in part, "No, she didn't tell me they were on suicide precautions."

10. An interview was conducted with RN #1 on 05/22/19 at 9:20 a.m. When asked why patient #19 did not have a sitter to ensure continuous monitoring she stated in part, "I didn't know he was on constant observation and I assume the aide got report and would know." When asked if she was aware that the patient was a suicidal ideation patient she stated in part, "Yes, I knew. He's well known to us." When asked if she could explain the emergency room 's policy on suicidal ideation patients she stated in part, "Yes, they all have to have someone with them in the room."

11. An interview was conducted with the Chief Nursing Officer (CNO) on 05/22/19 at 9:35 a.m. She concurred with the above findings and that all ED patients with a diagnosis of suicidal ideations require one (1) on one (1) monitoring.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, observation, policy review and interviews it was determined the Director of the Emergency Department (ED) failed to ensure supervision of care on patients who were diagnosed with suicidal ideation in the ED were monitored one (1) on one (1) in six (6) out of eight (8) patients diagnosed with suicidal ideations (patients #1, #2, #4, #5, #6 and #19). This failure has the potential for all patients who present to the ED to receive unsupervised care by a Registered Nurse (RN) that could lead to the death of a patient.

1. Review of the medical record for patient #1 revealed a twenty-four (24) year old male who (MDS) dated [DATE] at 4:11 a.m. with complaints of wanting to kill himself by hanging. A medical screening was completed on 3/21/19 with a diagnosis of acute suicidal ideations and acute major depressive disorder with current active episode. An order for continuous monitoring was ordered. No documentation of continuous monitoring was noted in the medical record.

2. Review of the medical record for patient #2 revealed a thirty-one (31) year old male who (MDS) dated [DATE] at 5:35 a.m. with complaints of suicidal ideations with a plan to jump off a bridge to commit suicide. A medical screening was conducted on 03/21/19 at 4:15 a.m. A differential diagnosis of suicidal ideations, illicit drug use and depression were given and suicide precautions were ordered. No documentation of continuous monitoring was noted in the medical record.

3. Review of the medical record for patient #4 revealed a fourteen (14) year old female who (MDS) dated [DATE] at 8:17 p.m. with complaints of suicidal thoughts with a plan to cut herself and leave a note. A medical screening was completed on 03/21/19 at 8:19 p.m. A differential diagnosis of suicidal ideations and depression was given. The patient was placed on suicide precautions. No documentation of continuous monitoring was noted in the medical record.

4. Review of the medical record for patient #5 revealed a twenty-seven (27) year old male who (MDS) dated [DATE] at 9:19 p.m. with complaints of depression. A medical screening was completed on 4/22/19 at 9:23 p.m. A differential diagnosis of depression and detox from multiple substances was made. An order was placed for continuous monitoring. No documentation of continuous monitoring was noted in the medical record.

5. Review of the medical record for patient #6 revealed a fifty-three (53) year old male who (MDS) dated [DATE] at 11:18 p.m. with complaints of needing to detox and drinking liquid laundry detergent in a Gatorade bottle. A medical screening was completed on 04/22/19 at 11:20. A differential diagnosis was made of alcohol abuse, substance abuse disorder and depression. Suicide precautions were ordered. No documentation of continuous monitoring was noted in the medical record.

6. Review of the medical record for patient #19 revealed a sixty-three (63) year old male who (MDS) dated [DATE] at 3:22 a.m. with complaints of depression and suicidal ideations with a plan to jump off a bridge. A medical screening was completed on 05/22/19 at 3:33 a.m. A differential diagnosis of suicidal ideations was made and an order was placed for continuous monitoring. No documentation of continuous monitoring was noted in the medical record.

7. Observation of the ED on 05/22/19 at 9:00 a.m. revealed an ED board patient #19 admitted with suicidal ideations. No ED staff was observed in the patient's room.

8. Review of the policy titled Suicide Prevention with a last review date of 06/2017 states in part: "All patients on suicide precautions that reside on an unlocked unit will require 1:1 observation."

9. An interview was conducted with Medical Assistant #1 on 05/22/19 at 9:15 a.m. When asked if she was to monitor patient #19 she stated in part, "I didn't know. I didn't get report this morning so I started cleaning up after night shift." When asked if the Registered Nurse (RN) caring for the patient had asked her to sit with the patient she stated in part, "No, she didn't tell me they were on suicide precautions."

10. An interview was conducted with RN #1 on 05/22/19 at 9:20 a.m. When asked why patient #19 did not have a sitter to ensure continuous monitoring she stated in part, "I didn't know he was on constant observation and I assume the aide got report and would know." When asked if she was aware that the patient was a suicidal ideation patient she stated in part, "Yes, I knew. He's well known to us." When asked if she could explain the emergency room 's policy on suicidal ideation patients she stated in part, "Yes, they all have to have someone with them in the room."

11. An interview was conducted with the Chief Nursing Officer (CNO) on 05/22/19 at 9:35 a.m. She concurred with the above findings and that all ED patients with a diagnosis of suicidal ideations require one (1) on one (1) monitoring.
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
Based on medical record review, policy review and interviews it was revealed the nursing staff failed to document on six (6) of eight (8) patients (patients #1, #2, #4, #5, #6 and #19) who were on one (1) to one (1) (1:1) continuous monitoring and one (1) of four (4) patients (patient #20) who was in restraints as required by hospital policy. This failure has the potential to affect all patients who require 1:1 continuous monitoring or are in restraints.

Findings include:

1. Review of the medical records for patient's #1, #2, #4, #5, #6 and #19 revealed continuous 1:1 monitoring was ordered and no documentation was noted of the monitoring in the patient's medical record.

2. Review of the medical record for patient #20 revealed restraints were ordered and no documentation was noted of the monitoring of the patient in the medical record after restraints were applied.

3. Review of the policy titled Suicide Prevention with a last review date of 6/2017 states in part: "Documentation must be done on the emergency room q 15 minute suicide precaution form. The documentation must be done from the time of suicidal assessment until the patient is transferred to another level of care..."

4. Review of the policy titled Seclusion and Restraints with a last review date of 3/2018 states in part: "Documentation about seclusion or restraints will include: Assistance provided to the patient to help him/her meet the behavior criteria for discontinuation of seclusion or restraint. Continuous monitoring..."

5. An interview was conducted with the Chief Nursing Officer (CNO) on 5/22/19 at 9:35 a.m. and she concurred documentation was not completed on patients ordered 1:1 continuous monitoring.

6. An interview was conducted with the Emergency Department Manager on 5/22/19 at approximately 9:45 a.m. and she concurred restraint documentation had not been completed on patient #20.