HospitalInspections.org

Based on medical record review, documentation review, and interview, it was revealed the facility failed to notify a patient's legal guardian prior to discharge for one (1) of ten (10) patients (Patient 1). This failure has the potential to negatively impact all patients receiving care at the facility.

Findings include:

A medical record review was conducted for patient #1. The patient is a newborn delivered via Caesarean section at the facility on 3/27/25 at 3:24 a.m. The record contains an entry titled "History and Physical" completed on 3/27/25 at 11:49a.m. by staff 14 which includes a section titled "Assessment/Plan" which states, in part, " ...Social: SW [Social Work] consult placed, appreciate recommendations ..." The medical record has an external document titled "Department of Health and Human Resources" (DHHR) dated 3/28/25. This document states the biological parents are to have no visitation or contact with [states patient 1's name]. The document names the foster parents and states that they are allowed contact and visit with patient 1. The medical record has an external document titled "West Virginia Department of Human Services" (DHS) dated 4/1/2025. This document outlines that the West Virginia Department of Human Services has legal custody of patient 1 and outlines the rights, responsibilities, and limitations of the foster parents' rights concerning patient 1. The medical record has a section titled "Case Management (CM) Transition Planning Follow Up ..." this section contains the following entries: an entry titled "Narrative Note" completed on 4/3/25 at 8:21a.m. by staff 5 states, in part, "Comment: ...CM asked if [cps 1] received a call from [staff 13] yesterday, [cps 1] stated, 'no, I did not have any missed calls.' "An entry titled "CM Narrative Note" completed on 4/2/25 at 9:54a.m. by staff 13 states, "SW [Social Worker] called [cps1], left VM [voice mail]. Waiting on a return call." An entry titled "CM Narrative Note" completed on 3/31/25 at 9:06a.m. which states, in part, "CM received call from [cps1] ...asking for an update on pt [patient]. CM spoke with NBN [newborn nursery] staff who stated pt could possibly dc [discharge] tomorrow, but nursery staff is waiting on doctor's recommendations during rounds. CM will follow up with [cps 1] after NBN rounds." May it be noted, there are no "CM Narrative Notes" dated 4/1/25, which is patient 1's date of discharge.

An email was reviewed titled "Handoff" dated Monday March 31, 2025, at 3:55p.m. This document was sent to staff 6, 10, 13 and others. The document contains a section titled "Newborn Nursery [NBN]" which states, in part, " ... [patient 1 parent] ... [cps 1] ...called stating [patient 1] should not be with parents. Letter on chart. Possible discharge (DC) tomorrow as long as [patient 1] does not need any medication for withdraw, [cps 1] asked that we call [him/her] in the morning if patient will be ready for DC so [he/she] can send over petition."

An interview was conducted with staff 12 on 4/8/25 at 3:00p.m. Staff #12 was asked about the process of discharging a patient in DHHR custody. Staff #12 stated, "If we have a social work consult, [he/she] makes the CPS referral if necessary. If CPS takes custody of the patient, we need a ratification letter. The previous social worker had said that the initial letter was okay. We make a copy of foster parent identification but there is no policy about this process. In a perfect world, the social worker should be rounding, looking at who is going home."