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Based on observations, review of facility documents and interview with staff (EMP), it was determined that the hospital failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program as evidence by failing to: collect and use data to monitor effectiveness and safety of services and quality of care, analyze adverse patient events, such as reports of self-injurious behavior, and incidents of verbal and physical abuse and altercations, in order to identify patterns, causes and level of severity so that appropriate measures can be implemented to reduce occurrences and improve patient safety (A0273). In addition, the hospital's QAPI program failed to include accurate tracking of physical environment assessments and progress on an environmental improvement project that focused on replacing current beds to anti-ligature/ligature resistant beds (A0283).

Cross Reference:
§§482.21(a), 482.21(b)(1), 482.21(b)(2)(i), & 482.21(b)(3) Data Collection & Analysis
§§482.21(b)(2)(ii), 482.21(c)(1) & 482.21 (c)(3), 482.21(b)(2) Quality Improvement Activities

Based on observations, review of medial records (MR) and facility documents, and interview with staff (EMP), it was determined that the hospital failed to maintain adequate staffing of qualified personnel and supportive staff as evidence by: failing to ensure that there were adequate numbers of mental health therapists and ongoing active treatment provided to patients (A1704); failing to provide social services in accordance with acceptable standards of practice (A1715); and failing to provide therapeutic activities appropriate to the needs and interests of patients, and geared at restoring and maintaining optimal levels of physical and psychosocial functioning (A1725).

Cross Reference:
§482.62(d)(2) There must be adequate numbers of registered nurses, licensed practical nurses, and mental health workers to provide the nursing care necessary under each patient's active treatment program.
§482.62(f) Standard: Social Services
§482.62(g)(1) The program must be appropriate to the needs and interests of patients and be directed toward restoring and maintaining optimal levels of physical and psychosocial functioning.

Based on review of medical records (MR), facility documents and interview with staff (EMP), it was determined that the hospital failed to collect and use data to monitor effectiveness and safety of services and quality of care, failed to analyze adverse patient events, such as reports of self-injurious behavior and incidents of verbal and physical abuse and altercations, in order to identify patterns, causes and level of severity so that appropriate measures can be implemented to reduce occurrences and improve patient safety.

Findings include:

Review of facility policy, "Quality Assurance Performance Improvement (QAPI) and Patient Safety Plan," effective January 2023, revealed "Purpose This plan establishes a collaborative, planned, systematic and organization-wide approach to measure, assess, and improve the quality of care and patient outcomes while continuing to identify and reduce safety risks to patients ... this is achieved by: ... Supporting effective responses to adverse occurrences, focusing on review and improvement of processes and systems ... Practicing ongoing proactive risk reduction to avoid medical/healthcare errors, Integrating patient safety priorities into the design and redesign of significant organizational processes, functions, and services ... . Goals/Objectives The goals of QAPI and patient safety plan are to maintain and improve the quality of patient care; enhance appropriate utilization of resources design, measure, assess, and improve hospital processes; and reduce or eliminate unnecessary risks and hazards within the facility. ... The objectives of the QAPI and Patient Safety Plan include: ... 2. Continue to maintain an efficient and effective system of data management .... Review and analyze the data for relevant trends, identifying new improvement opportunities, and/or verifying the effectiveness of action plans within the Quality Council monthly. 12. QAPI Coordinator will review all departmental QAPI's, retiring QAPI's that have been stable with positive outcomes and initiating with departmental leaders new QAPI projects. Allocation of Resources ... An adequate number of staff members will be assigned to, and given sufficient time to participate in Quality, Performance Improvement, and Safety activities to ensure thorough and timely completion of projects. Hospital Leadership will provide informational and technical resources to support the improvement of processes .... Prioritization of QAPI Activities Prioritization of all QAPI projects and activities is performed by the leadership of Sharpe Hospital each year and adjusted promptly in response to urgent or unusual events. The intent is for the QAPI activities to be directed toward those issues that actually or potentially affect health outcomes, patient safety, and quality of care. ... Data Collection ... Data that the organization considers for monitoring performance includes, but is not limited to the following: ... Patient safety events ... Intense analysis and/or root cause analysis action plans, plan of correction reports related to findings of regulatory agencies ... Proactive identification and reduction of unanticipated adverse events and safety risks, Failure mode effects analysis ... Hospital performances improvement projects, their purpose, and the measurable progress achieved. ... The hospital also collects data to monitor processes that involve risks, or which may result in a sentinel event. At a minimum, performance measures will be identified for the following processes: ... Care of services provided to high-risk populations ... Aggregating and Analyzing Data ... Various statistical tools are used to analyze and display data. ... Data is aggregated and analyzed within a timeframe appropriate to the process or area of study. Data will be analyzed to identify system changes that will help improve patient safety. Proactive Risk Reduction to Improve Patient Safety At least one high-risk process shall be proactively analyzed every eighteen months. ... Achieving Improvement/Risk Reduction Sharpe Hospital's intent and objective is to use these data collections and analyses for identifying systems and processes that may need changes for improving quality of care and services, improving staff performance, and improving patient safety by reducing the risk of adverse events. ..."

Review of MR1's "Psychiatric Evaluation," dated November 16, 2022, revealed that the patient was admitted to the hospital, after serving time in a prison, via a "probable cause" court order due to "increased delusions, auditory and visual hallucinations, and history of threats and aggression." [A "probable cause" hearing is a court proceeding to determine if an individual requires involuntary commitment for treatment at a psychiatric facility because of being deemed addicted to a controlled substance or mentally ill and likely to cause harm to themselves or others. (Legal Aid of West Virginia. (2021, April 14). Mental Hygiene Process. www.legalaidwv.org)].

Review of facility documentation revealed that MR1 was involved in multiple incidents since their admission to the facility. These incidents involved multiple altercations and physical attacks on other patients and staff, which resulted in injuries. Many of the events were categorized as "Patient to Patient" incidents.

A review of facility documentation revealed no evidence that patient-to-patient and patient-to-staff incidents/events, were being analyzed, tracked or trended in order to mitigate reoccurrence and improve patient safety.

Interview on May 16, 2023, at 9:54 AM, with EMP5 indicated that the hospital tracks abuse and neglect through QAPI program, the number of "Patient to Patient" incidents and if the reported event is a categorized as a "Patient to Patient" incident. However, it was indicated that the circumstances and causes of each "Patient to Patient" incidents were not being analyzed or reviewed to identify patterns and causes to mitigate reoccurrence, only the number and type of events being reported.

Review of MR24 revealed that the patient was admitted to the facility on May 27, 2022, after being incarcerated. Further review of the patient's medical record revealed that the patient had a history of impulse control disorder, Autism, Intellectual Developmental Disorder, and a history of self-injurious behaviors.

Review of facility documentation revealed that the patient attempted suicide by trying to hang themselves with their bedsheets on February 24, 2023.

A review of facility documentation revealed no evidence that self-injurious behaviors, to include suicide attempts, were being analyzed, tracked, or trended to mitigate reoccurrence and improve patient safety.

Based on observations, review of facility documents and interview with staff (EMP), it was determined that the hospital's QAPI program failed to include accurate tracking of physical environment assessments and progress on an environmental improvement project that focused on replacing current beds to anti-ligature/ligature resistant beds.

Findings include:

Review of facility policy, "Quality Assurance Performance Improvement (QAPI) and Patient Safety Plan," effective January 2023, revealed " ... Quality Safety Management Committee This committee's primary responsibility for reporting life safety and environment of care requirements and regulations which promote and support organizational patient safety activities. ... The Safety Committee meets monthly, and reviews reports and data analysis pertaining to safety management ... patient, visitor, and staff safety issues ...".

Observation of MR2's room, located on "G1", on May 15, 2023, at 9:15 AM, revealed a wooden bed with five restraint attachment points on each side of the bed.

Observation of an unoccupied patient room, located on "E1", on May 16, 2023, at 10:10, with EMP22, revealed a wooden bed with five restraint attachment points on each side of the bed. Interview with EMP22, revealed that these beds were in the process of being replaced because the restraint attachment points posed as a ligature risk. Observation of a seclusion room, located on "E2," where MR24 was laying down, revealed a bed made of plastic with triangular metal hardware along the bottom edge of the bed. Interview with EMP22 indicated that the metal hardware was utilized to attach restraint devices. EMP22 confirmed that these areas posed as a ligature risk as they could be utilized as a tie-off point.

Interview on May 16, 2023, at 11:06 AM, with EMP53 revealed that the facility was in the process of replacing the wooden beds that contained the restraint attachments and were removing the triangular metal hardware from the plastic beds. EMP53 indicated that "80 percent of the beds had been replaced" but they did not keep a list of which beds had been replaced and which of the beds had the triangular metal hardware removed.

Interview on May 17, 2023, at 10:34 AM, with EMP53 revealed that the facility was replacing the beds unit by unit and were checking the units monthly to ensure that the beds were replaced, and the metal hardware removed from the other beds. However, EMP53 provided no documented evidence that the units were being checked monthly to ensure beds were replaced or metal hardware removed as planned. EMP53 indicated that there were 200 beds in the facility but 49 had yet to be replaced. It was revealed that the beds in the seclusion room and beds stored in the visitor rooms were not being accounted for and EMP53 did not know how many of those beds needed to be replaced or had metal hardware that needed to be removed. In addition, EMP53 indicated that they do attend the QAPI meeting, but that progress regarding this safety project of replacing these beds or removing the metal hardware was not discussed during the QAPI meeting.

Interview on May 17, 2023, at 3:12 PM, EMP53 indicated that they don't keep a running list of what beds have been replaced. EMP53 provided a document, untitled and undated, that indicated there were ten wooden restraint beds on unit "E1" and one wooden restraint bed on unit "G2." Further review of the document revealed that the wooden restraint bed observed on "G1" was not included in the list.

Interview on May 18, 2023, at 1:39 PM, with EMP1 revealed that they were aware of the bed replacement project since July 2022 but that it was not being addressed in the Quality Safety Committee. EMP1 indicated that it was reported to them that beds in certain patient care units were replaced. However, EMP1 indicated that they observed that there were still beds in those areas that needed to be replaced. EMP1 confirmed that this project was not being adequately monitored nor accurately tracked.

Based on review of medical records (MR), review of facility documents, and interview with staff (EMP), it was determined that the facility failed to ensure that there were adequate numbers of mental health therapists and failed to ensure that active treatment was provided in accordance with patient treatment plans for one medical record reviewed (MR1).

Findings include:

Review of MR1's "Master Treatment Plan," initiated on November 22, 2022, revealed "Treatment Area 1: Psychological Impairment (Bipolar Disorder, IDD [Intellectual or Developmental Disability], Impulse Control Disorder- Antisocial Personality Disorder, ADHD [ Attention Deficit Hyperactivity Disorder] As evidenced by the following signs/symptoms: According to admission documentation, [patient] states [patient] has a CIA microphone that was implanted by the military and if they turn it off [they] can't hear but others were not able to hear all that [they] hears. [Their] special contacts allow [them] to see much more than ordinary people.

The patient's treatment plan revealed the following therapeutic modalities: "Healthy Living Group: Mental Health Therapist will provide [patient] an opportunity to participate in a practical life skill intelligence group by actively participating; creating the life [patient] desires and to access [their] inner resources needed to succeed such as: Problem Solving; Money Management; Time Management; Self-Awareness; and Personal Change. ... group experiences revolving around identified topics of importance to improve [their] psychological stability. Measurement will be based on [patient's] response, observed participation, mood, and behavior within a group setting. Personal [sic] Responsible: EMP33, Mental Health Therapist Personal Empowerment Group: [Patient] will be provided with Personal Empowerment group twice weekly to aid [patient] in learning and utilizing problem-solving skills, interpersonal communication skills, and positive coping skills and strategies to establish and maintain psychological stability. Person Responsible: EMP34, Mental Health Therapist ...".

Review of MR1 revealed no evidence that "Healthy Living Group" therapy sessions were provided to the patient. Moreover, review of the patient's record indicated that the patient participated in "Balancing Emotions Group" therapy, as treatment to the patient's psychological impairment, for a total of three times, on December 21, 2022, January 4, 2023, and again on February 23, 2023.

Review of MR1's "Mental Health Therapist" progress note, dated February 23, 2023, by EMP33, revealed that the patient attended a "Balancing Emotions" group therapy session. The session focused on "mindfulness", and it was documented that the patient fully participated. EMP33 documented that the plan would continue, offering and encouraging the patient's participation as well as 1:1 alternatives as needed. This was the last progress note related to the patient's participation in "Balancing Emotions" and last note documented by a Mental Health Therapist (EMP33).

Review of MR1's "Master Treatment Plan" revealed an "addendum," dated April 5, 2023, indicating that the "Personal Empowerment Group" was discontinued, and "status" was documented as "completed." The patient's medical record revealed no documented evidence that "Personal Empowerment" therapy sessions were provided to the patient in accordance with the patient's treatment plan.

Review of the facility's group therapy schedule revealed that EMP33 facilitated the "Balancing Emotions" therapy sessions and EMP34 facilitated the "Personal Empowerment" therapy sessions. Further review of the schedule revealed that several patients throughout the facility were scheduled for these therapy sessions but there was no documented evidence that the facility continued these two therapeutic modalities for or included MR1.

During a meeting held on May 18, 2023, at 2:30 PM, with EMP1, EMP4, EMP5, EMP14, EMP36, EMP49, to discuss the facility's Quality Assurance and Performance Improvement (QAPI) program, EMP49 revealed that the facility has not had "many mental health therapists for a while" but that the facility is working on hiring more.

The facility failed to ensure that there were adequate numbers of mental health therapists and failed to ensure active treatment was provided in accordance with a patient's treatment plan.

Based on review of medical records (MR) and review of facility documents, it was determined that the facility failed to provide social services in accordance with accepted standards of practice in order to facilitate continued active treatment with patient treatment plans for one medical reviewed (MR1).

Findings include:

Review of MR1's "Master Treatment Plan," initiated on November 22, 2022, and modified on April 5, 2023, revealed "Treatment Area 3: Discharge/ Community Issues ... As evidenced by the following signs/symptoms: According to admission documentation, [patient] will go to a group home/facility upon [their] discharge from the hospital. However, [patient] has been denied at most in state placements and out of state options are being explored at this time. ... Interventions: Social Worker: Staff will meet with [patient] weekly and as needed to provide [them] with the opportunity to discuss the resources available to [them] and how they can help [patient] stay in the community to demonstrate discharge readiness and promote successful community living. Responsible Person(s): EMP58, PLSW [Provisional Licensed Social Worker]/ EMP59, LSW [Licensed Social Worker].

Review of a "Social Work Progress Note," dated March 15, 2023, revealed "Intervention: Individual Staff will meet with [patient] weekly and as needed to provide [patient] with the opportunity to discuss the resources available to [them] and how they can help [them] stay in the community to demonstrate discharge readiness and promote successful community living. Response: Social worker met with [patient] on the unit. [Patient] said that [they] wanted to get a house with [name of real estate company]. [Patient] was carrying a notebook and showed social worker where [they] had the name of [name of real estate company] in [their] notebook. [Patient] did not need anything else at this time. ...".

Review of "Social Work Progress Note," dated April 5, 2023, revealed "Intervention: Individual Staff will meet with [patient] weekly and as needed to provide [patient] with the opportunity to discuss the resources available to [them] and how they can help [them] stay in the community to demonstrate discharge readiness and promote successful community living. Response: a review staffing was held today by the treatment team with [patient]. The provider and [patient] discussed [patient's] attendance to groups and fresh air ...".

Further review of the "Social Work Progress Notes" revealed no documented evidence that interventions specific to the patient's "Treatment Area 3," was implemented. In addition, there were no additional meetings held with the social worker and the patient, on weeks when a "treatment team meeting" occurred nor was there documented evidence that this goal was worked on during those meetings.

Review of "Social Work Progress Note," dated April 10, 2023, by EMP60 (a PLSW), revealed "Intervention: Individual Staff will meet with [patient] weekly and as needed to provide [patient] with the opportunity to discuss the resources available to [them] and how they can help [them] stay in the community to demonstrate discharge readiness and promote successful community living. Response: Social worker met with [patient] on the ... unit. [Patient], earlier this day was aggressive [sic] with staff (punching in the face and pulling out a handful of hair of [EMP61, Registered Nurse]). [Patient] is currently on 2:1 for safety. ...".

Review of "Social Work Progress Note," dated April 28, 2023, by EMP60, revealed " ...Intervention: Individual Staff will meet with [patient] weekly and as needed to provide [patient] with the opportunity to discuss the resources available to [them] and how they can help [them] stay in the community to demonstrate discharge readiness and promote successful community living. Response: Social worker met with [patient] on G2 unit. [Patient], earlier this day was aggressive [sic] with staff (punching in the face and pulling out a handful of hair of [EMP61, Registered Nurse]). [Patient] is currently on 2:1 for safety. ... Assessment/Progress Toward Goal (s): Social worker and the provider went down to N3 to do a round with [patient]. This social worker asked how [patient] has been feeling since a physical altercation the prior day that wasn't [patient's] fault. [Patient] was lying in bed but was in good spirits and stated that [they] was still in some pain. Social worker advised [patient] that [patient] is handling the entire incident well and to continue to keep a positive attitude. Once [patient] is healed the team will start on [patient's] discharge."

Further review of the note revealed inconsistent and inaccurate information and there was no evidence that each encounter, completed by EMP60, was reviewed by a licensed social worker. In addition, there was no documented evidence that discharge was actively being worked on prior to these incidents nor that the patient would be ready for discharge once "healed" from the incident with a peer.

Review of MR1's "Social Work Progress Notes," from March 15, 2023, through May 4, 2023, revealed a lack of structure regarding the occurrence and content of the meetings and there was no documented evidence that the social workers were providing individualized active treatment as outlined in the patient's treatment plan.