HospitalInspections.org

Based on record review, document review and staff interview it was determined that Employee #8, failed to supervise the adolescent unit during a Code M. This failure has the potential to negatively affect all patients receiving services at the facility.

Findings include:

A review of the medical record for patient #1 revealed the patient was admitted to the hospital on 08/13/25, with a diagnosis of suicidal ideations. On 08/17/25 at approximately 9:30 p.m. A code M was activated the patient began to escalate over an earlier incident where the patient was placed on Close Visual (CV). The patient did not like being constantly watched. Two (2) MHS (Mental Health Specialist) tried to de-escalate the patient.
A review of the staffing sheets for the 08/17/25, 7:00 p.m. to 7:00 a.m. shift revealed one (1) RN and two (2) MHS were scheduled.

A review of the job description titled "RN III" with a date of last change 07/29/25. States in part, "Job Profile name: RN III ...Job Profile Summary This position has the authority, responsibility, and shift accountability for the delivery of nursing care through the use of the nursing process. The incumbent accepts accountability, applies competent clinical knowledge skills, and uses independent nursing judgment for care provided by self and by health care providers to whom care is delegated to achieve quality patient care outcomes. Performs the duties and responsibilities within the scope of a Registered Nurse (RN) ..."

A review of a policy titled "CODE M (MORE ASSISTANCE) RESPONSE TEAM" with a last reviewed date of 06/07/23. States in part, "It is the policy of West Virginia University Hospitals (WVUH) to support a specially trained team to provide an effective and efficient response to any request for MORE ASSISTANCE (Code M) for a patient, visitor, or staff member, who may be emotionally and physically escalated ...All available staff from the primary unit and all available staff from near neighboring units will respond as show of support. Staffs educated in non-violent crisis intervention skills are to be the first responders. Roles: Staff nurse: communicates with patient and team. The response team will provide non-violent crisis intervention during events that occur in patient care areas ..."
A telephone interview was conducted with employee #2 on 08/25/25 at 11:40 a.m. When asked to explain the incident with patient #1 on August 17th? They stated in part; "I came to the unit as part of the Code M team. When I got there, they were removing items from the patient's room because they threatened self-harm. The patient began to get upset because they had a CV and me and another worker were explaining why they got the CV. The [states employee #8's name] left the unit for a while ..."

An interview was conducted with employee #5 on 08/26/25 at 6:45 a.m. When asked to explain the incident with patient #1 on August 17th? "I was at the door of [states patient #1's name] trying to de-escalate them along with another MHS. [states employee #8's name] was upset and we don't know why they got so upset that night because they weren't even on the unit when the patient started ripping the Velcro door off of the bathroom door and throwing it. They had left the unit to go find [states employee #7's name]. When asked if there was another nurse on the unit? They stated, "No, [states employee #7's name] was pulled to work another unit."

An interview was conducted with employee #6 on 08/26/25 at 7:46 a.m. When asked what the process is for a nurse to contact a charge nurse or a nursing supervisor? They stated in part, "The process is you start with the charge nurse, and you contact them by either texting them or calling them on their phone." When asked if the unit should be left with no registered nurse (RN)? They stated in part, "No, they should be using their phones to contact them instead of leaving the unit."

A telephone interview was conducted on 08/26/25 at 8:00 a.m. with employee #7. When asked to describe their involvement with patient #1 on August 17th? They stated in part, "I was on another unit when [states employee #8's name] came to the unit and wanted me to come back to the unit to see 'inappropriate behavior' between two [2] MHS workers and a patient. I went to the unit where the MHS workers were calmly explaining the CV order to the patient. When asked if there was another RN on the unit while employee #8 was off the unit? They stated in part, "No other RN was on the unit when they went left the unit to get me."

A telephone interview was attempted on 08/26/25 at 9:20 a.m. with employee #8. A Voice message was left to please return this surveyor's phone call. It should be noted the employee never contacted this surveyor back.