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Based on observation and documentation review it was determined the hospital failed to meet West Virginia Administrative Rule, Department of Health and Human Resources Series 59: Behavioral Health Patient Rights. This has the potential to adversely affect the privacy, safety, and comfort of all hospital patients admitted above the one hundred fifty (150) bed capacity. Findings include:

1. Title 64: West Virginia Administrative Rules, Department of Health and Human Resources Series 59: Behavioral Health Patients Rights Rule 1995

64-59-2 Application and Enforcement

2.1 Application - This rule applies to State - operated behavioral health facilities.

15.2.1 Each facility shall provide furnishings and equipment which are clean and in good condition, and appropriate to the age and physical conditions of the clients. Every client shall be provided with a normalized, comfortable and attractive living space.

15.2.4 Each bedroom shall provide a minimum of one hundred (100) square feet per client, excluding closets.

15.2.5 All bedrooms shall have outside windows, be above ground level, and provide adequate space for client privacy.

2. The hospital has facilities to accommodate one hundred fifty (150) patients. Census records showed one hundred fifty-seven (157) patients during this complaint investigation conducted on 12/06/10 to 12/09/10.

3. A review of the facility's "overbedding" policy and procedure revision dated 04/02/09 was made on 12/08/10 at approximately 8:30 a .m. This policy indicated that when the hospital exceeds the one hundred fifty (150) bed capacity, portable cots will be used in private rooms (for ten (10) patients). During tour of the units on 12/06/10 at approximately 2:15 p.m., cots were observed in use in some of the private rooms. These private rooms do not meet the design standards for two (2) patients. The policy also states that the next four (4) overbedded patients will be placed in the conference rooms located on units E2 and G2. These rooms are not provided toilet/bathing facilities within the room and the patient must first go into the corridor then to an assigned toilet/bathing room in a semi-private room. The policy also identified the seclusion rooms, group rooms and visiting rooms for housing of patients, when needed. These rooms do not have an outside window and do not meet the requirement of one hundred (100) square feet per patient.

4. On 12/08/10 at approximately 9:00 a.m., a review of the hospital's daily census reports was made for the time period of 09/01/10 to 12/05/10. These report's revealed that the one hundred fifty (150) bed capacity was exceeded ninety-five (95) of ninety-six (96) days. Also, during the time period of 11/21/10 to 12/01/10 the daily census was one hundred seventy (170) to one hundred seventy-three (173).

5. This practice of housing patients above the one hundred fifty (150) bed construction design capacity places patients in an environment where confidentiality and safe, comfortable conditions cannot be provided.

Based on review of documents and staff interview, the governing body failed to provide sufficient evidence it has been responsible for the effective conduct of the hospital by failing to provide suitable heating facilities for all patient care areas. Findings include:

1. A review of the governing body bylaws dated 2009 indicated the president and vice president of the governing body also hold administrative positions in the WV State Government Bureau of Behavioral Health.

2. The governing body was unable and failed to take the necessary steps to ensure an adequate heating system was in place and operating for all patient care areas for the cold weather months.

3. A review of the governing body meeting minutes for the quarter prior to this investigation indicated that the maintenance department had determined as early as April, 2010 that when they repaired two (2) of the underground lines for the heating/cooling system, additional new leaks developed and that anything less than the replacement of all four (4) lines would not resolve the heating problem.

4. During interview with the Chief Financial Officer on 12/8/10 in the a.m., she provided a letter she had written to the Department of Health and Human Resources (DHHR) purchasing department dated 9/28/10 requesting an expedited approval to rent two (2) portable boilers at a cost of $32,000 (thirty-two thousand dollars) per month as a temporary fix. Even while the portable boilers are in operation during this investigation, at least five (5) patient rooms were at temperatures between 59 and 61 degrees. There has been no documented approval to begin permanent repairs of the heating/cooling system.

5. Even after considering the steps indicated above, at the time of this investigation the hospital remains too cold in several patient rooms. Rooms C105, 106, 107, 108 and 109 had temperatures between 59 and 61 degrees F. There is also no definitive evidence of how or when the governing body foresees this heating problem will be resolved.

Based on observation, staff interview, and documentation review during the survey conducted 12/06/10 to 12/09/10, it was determined due to the volume of deficiencies issued to the hospital for non-compliance with the 2000 Edition of the Life Safety Code, and deficiencies generated relating to the physical plant, that the hospital failed to maintain the environment to ensure the safety of the patients, staff, and public. Therefore this Condition is not met. Refer to Life Safety Code deficiencies identified as tag numbers K052, K062, K064, K069, and K160 and physical environment tags identified as A0701 and A0722.

Based on observation and staff interview it was determined the hospital failed to maintain the personal privacy of two (2) patients (patients #14 and 15) who were provided a classroom with large uncovered windows for a bedroom. This failure creates the potential for the violation of the privacy rights of all patients who are placed in rooms which were not designed to serve as bedrooms. Findings include:

1. A tour of the G2 unit was conducted at 1140 on 12/6/10. At that time a classroom with large outside windows was observed to contain two (2) beds. Patients #14 and #15 were noted to be utilizing this classroom as a bedroom. Thirteen (13) of the windows in the room were observed to be uncovered. The classroom had no adjoining bathroom for dressing/undressing. Patients are not provided personal privacy for dressing and undressing in this area.

2. This situation was discussed with the Unit Nurse Manager who acknowledged the windows lacked coverings.

Based on review of employee education files, hospital policy and staff interview it was determined the hospital failed to ensure nursing staff who provide care to patients complete a nursing orientation. This failure involved two (2) of two (2) full time nurses reviewed (RN 1 and RN 2). This failure creates a potential for nursing services to be inadequately staffed by nurses who have not been trained. Findings include:

1. An interview was conducted with the Staff Development Director in the morning of 12/7/10. He stated that general orientation for new employees is provided by Staff Development. He stated that nursing staff then complete a nursing orientation provided by the nursing department.

2. Policy #03.800 "Nursing Orientation," effective date October 1993, was provided for review. The policy states in part: "On employment of a RN (Registered Nurse), LPN (Licensed Practical Nurse) or HSW (Health Service Worker) an assessment will be done by Staff Development to determine policies and procedures that are necessary for the new employee to become proficient in before he/she is allowed to perform them in an unsupervised situation.

Check sheets will be provided for each Nursing employee. The check sheet will list the procedures which need taught and/or supervised. The preceptor responsible for the teaching/supervision and the date it was determined by the instructor/preceptor that the new nursing employee became proficient in the procedure...

After check sheet has been completed it will be forwarded to Staff Development for filing in the employee's education file."

3. Review of education file for RN#1 revealed she was hired on 9/1/10. The education file did not contain a nursing orientation check sheet.

4. Review of education file for RN #2 revealed she was hired on 10/4/10. The education file did not contain a nursing orientation check sheet.

5. During an interview with the interim Director of Nursing (DON) in the afternoon of 12/8/10 the education files for RN #1 and 2 were reviewed and discussed. She stated the orientation check sheets for these nurses could not be located. She indicated RN #1 and 2 still had the nursing orientation check sheets and the check sheets were most likely not completed yet. The Interim DON also confirmed that both nurses have already been working without the supervision of a preceptor.

Based on staff interview and documentation review it was determined the hospital failed to maintain the environment in a manner to assure the safety and comfort of all patients. Findings include:

1. On 12/06/10 at approximately 11:00 a.m. an interview with the building/grounds manager revealed that an interruption in the heat supply system occurred sometime early morning on 12/06/10. This interview also revealed that there was no patient room temperature monitoring for the rooms that were affected by the heat interruption. On 12/06/10 at approximately 2:15 p.m., the building/grounds manager and the surveyor went to the unit (C1) that had the heat interruption. At this time, the building/grounds manager tested the ambient room temperature and found five (5) patient rooms (C105, 106, 107, 108, and 109) with room temperatures between 59 and 61 degrees F.

2. The hospital's policy and procedure plan for interrupted heat supply indicates that maintenance staff will monitor patient room temperatures and when the room temperature drops below 69 degrees F. an electric oil-filled space heater will be used to supply heat to bring up the room temperature.

3. This practice of not following the hospital plan for heat interruption does not ensure a safe and comfortable environment for patients in the event of a facility heat interruption.

Based on observation it was determined the hospital failed to maintain the required special design consideration for a safe environment on patient care units by failing to remove potential looping devices. Findings include:

1. On 12/06/10 during the time frame of 12:30 p.m. and 2:30 p.m., a tour of the hospital patient care units was conducted. At this time, the following design requirements of American Institute of Architects (AIA) guidelines for Design and Construction of Health Care Facilities in reference to behavior/psychiatric units were observed not to be met.

2. Eighty (80) of eighty (80) patient care rooms had the following potential looping devices or tie-off points:

a. Corridor, toilet, and closet room doors had lever-type door hardware.
b. Accessible/exposed toilet water service lines from wall.

3. Fourteen (14) of fourteen (14) handicap accessible rooms had open-type grab bars (open space between bar and wall/shower wall) in the shower stall and around toilet area. Also, these rooms have a flexible hose type shower handle.

4. Also, all units had a wall mounted rail/handrail in the corridors that was observed to have an open space between wall and rail/handrail.

5. Conference room on unit G-1 is being used for patient housing. The ventilation grill in this room was observed not to be tamper resistant and one (1) electrical outlet was observed not to be tamper resistant.

6. These conditions found in the patient care units are not giving the required special design consideration to prevent potential patient injury or suicide.

Based on document review and staff interview, it was determined the hospital failed to set priorities for its Quality Assessment/Performance Improvement (QA/PI) Program that are focused on problem-prone areas. This has the potential to adversely affect the patients physical and psychological well being. Findings include:

1. Review of the Continuous Quality Improvement (CQI) Committee Meeting Minutes from 5/1-10/31/10 revealed no data collection/discussion relative to the hospital's chronic overcrowding.

2. Review of the hospital's daily census from 9/01-12/05/10 revealed the hospital to be over its bed capacity ninety five (95) of the ninety six (96) days during this time period.

3. The Assistant Chief Executive Officer and the Director of Compliance were jointly interviewed in the afternoon of 12/07/10. Both revealed that due to the chronic overcrowding at the hospital, it's now considered to be the norm rather than the exception and although being discussed almost daily, it is not being documented. Both agreed it is not being formally addressed and focused on by the hospital's QA/PI Program.

4. Review of the Continuous Quality Improvement (CQI) Committee Meeting Minutes from 5/1-10/31/10 revealed virtually nothing relative to the hospital's ongoing heating system problem.

5. During interview with the Building'Grounds Manager in the morning of 12/08/10 he stated he reports relevant information to both the Assistant Chief Executive Officer and the Director of Compliance. However, he said he mainly reports to them verbally or via e-mail. He revealed he also reports to the Safety Committee, but doesn't know if it is forwarded on to the CQI Committee. Relative to the problem with the hospital's heating system, he said he is unaware if it is being formally addressed by the QA/PI Program.

6. The Director of Compliance was interviewed in the afternoon of 12/08/10. She agreed the heating system problem is certainly problematic and is being discussed. However, she agreed the problem is not being formally addressed by the QA/PI Program.