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 March 16, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
The hospital failed to maintain a safe setting for all patients on Unit 2 B as evidenced by the presence of looping devices in fifteen (15) of fifteen (15) patient rooms (See Tag A 144); and, the hospital failed to ensure nursing services filled out Occurrence Reports and Sentinel Event Reports to prevent possible strangulation to all patients admitted to Unit 2 B (See Tag A 144).
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A. Based on observation and staff interview it was determined the hospital failed to provide a safe setting for all patients as evidenced by the presence of looping devices in fifteen (15) of fifteen (15) patient rooms on Unit 2 B. This failure has the potential for all patients to have the ability to cause self harm or suicide by hanging or strangulation.

Finding include:

1. A tour of Unit 2 B (a behavioral health unit) on 3/14/16 at 10:13 a.m. with the Director of Plant Operations and the Program Director of Behavioral Health revealed patient rooms from two hundred twenty-seven (227) through two hundred forty-three (243) had a total of fifteen (15) patient rooms identified as containing looping devices that could cause patient harm. They included: All patient beds, desk, chairs, shower hoses, shower valves, sprinkler heads and door hinges.

2. An interview during the tour was conducted with the Program Director of Behavior Health and the Director of Plant operations and they concurred with the above findings.

B. Based on record review, document review and staff interview it was determine the hospital failed to follow hospital policies involving attempted strangulation in two (2) of two (2) medical records reviewed (patients #1 and 4). This failure has the potential for all patients to have the ability to commit self harm or suicide by hanging or strangulation.

1. Review of the medical record for patient #1 revealed she was admitted on [DATE] with a diagnosis of schizoaffective disorder. On 12/30/15 at 9:30 p.m., patient #1 presented to the nursing station with a reddened neck. Registered Nurse (RN) #1, RN #2 and Licensed Practical Nurse (LPN) #1 questioned her about how her neck became red and she admitted she had just tried to strangle herself with her bra. Nurse Practitioner (NP) #1 (on call) was notified and the patient was placed on one (1) on one (1) and in a room closer to the nursing station. No assessment or vital signs were documented at the time of the incident.

2. Review of the medical record for patient #4 revealed she was admitted on [DATE] with a diagnosis of suicidal ideation. On 1/25/16 at 7:01 p.m. patient #4 was found on the bathroom floor with a sheet on the floor beside her and her neck was reddened. The patient stated, "Suicide thoughts are there all the time." NP #1 was notified and the patient was placed on one (1) on one (1). No assessment or vital signs were documented at the time of the incident.

3. Review of the Nursing Supervisor end of shift report on 12/30/15 revealed the Nursing Supervisor was notified (no time documented for notification) of the attempted strangulation on patient #1. No Occurrence Report or Sentinel Event Report was initiated by RN #1, RN #2, LPN #1, NP #1 or the Nursing Supervisor.

4. Review of the Nursing Supervisor end of shift report on 1/25/16 revealed the Nursing Supervisor was notified (no time documented for notification) of the attempted strangulation on patient #4. No Occurrence Report or Sentinel Event Report was initiated by the nursing staff or the nursing supervisor.

5. Review of the policy titled, "Occurrences", last revised 8/2014, states, in part: "A reportable occurrence is any event, which is not consistent with normal hospital operations or routine patient care...Events of untoward, undesirable and usually unanticipated in the care of the patients."

6. Review of the policy titled, "Sentinel Event/Near Miss", last reviewed 3/2015, revealed, in part: "A near miss is a potential for more serious consequences."

7. An interview was conducted on 3/14/16 at 11:36 a.m. with NP #1. She concurred patient #1 and patient #4 both tried to strangle themselves and she did not fill out an Occurrence Report or a Sentinel Event Report. When asked why she failed to report an attempted suicide to administration through the hospital's reporting system she stated, "I just never thought about it."

8. An interview was conducted with RN #1 on 3/14/16 at 3:26 p.m. When asked if she remembered patient #1, she stated, "Yes." When asked if she documented an assessment or filed an Occurrence Report concerning the attempted suicide she stated, in part (after accessing Patient #1's medical record): "I didn't document an assessment and no I didn't fill out an Occurrence Report. We notified the Nursing Supervisor about the attempted suicide."

9. An interview was conducted with LPN #1 on 3/14/16 at 3:37 p.m. When asked if she remembered patient #1, she stated, "Yes." When asked if she filed an Occurrence Report involving the attempted suicide she stated, in part: "No, I didn't. I assumed the RN's did it."

10. An interview was conducted with RN #2 on 3/14/16 at 3:44 p.m. When asked if she remembered patient #1, she stated, "Yes." When asked if she documented an assessment or filed an Occurrence Report concerning the attempted suicide she stated, in part (after accessing Patient #1's medical record): "I didn't document an assessment; she wasn't my patient. And no, I didn't fill out an Occurrence Report and I'm not sure if the supervisor was notified."

11. An interview was conducted on 3/16/16 at 10:45 a.m. with the Director of Clinical Services. When asked what her expectation of assessment and documentation on an attempted suicide would be she stated, in part: "I would expect an assessment and vital signs to be done at the time of the incident and every four (4) hours until the patient was declared stable by the physician." She further stated she would expect an Occurrence Report to be filled out on anything out of the normal in patient care. During the interview she also concurred with the above findings.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on document review, record review and staff interview it was determined the hospital failed to ensure their Quality Assessment/ Performance Improvement (QA/PI) program identified and documented suicide attempts and elopements as "near miss" events in two (2) of two (2) records reviewed (patients #1 and 4). Failure of the QA/PI program to track and trend near miss events creates the potential for all patients to be adversely impacted by missing opportunities to prevent further suicide attempts or elopements.

Findings include:

1. Review of the facility policy entitled, "Sentinel Event/Near Miss", last reviewed 3/2015, defined, in part, a near miss as: "...incident with potential for more serious consequences" and "Responsibilities of the Director of Quality and Risk Management...gather detailed information about the event with the goal in mind of minimizing the risk of recurrence."

2. Review of the medical record for patient #1 revealed the patient eloped from the facility on 12/26/15 and attempted to commit suicide on 12/30/15 by strangulation.

3. Review of the medical record for patient #4 revealed the patient attempted to commit suicide on 1/25/16 by strangulation.

4. Review of the QA/PI program for 2015/2016 revealed there were no programs or action plans implemented for tracking suicide attempts or elopements in order to minimize the risk of recurrence.

5. During an interview with the Director of Quality and Risk Management on 3/15/16 at approximately 10:45 a.m. the above findings were discussed and she agreed the hospital failed to track the suicide attempts and elopement in order to minimize the risk of recurrence.
VIOLATION: NURSING SERVICES Tag No: A0385
The hospital failed to ensure the policy on Occurrence Reporting and Sentinel Reporting were followed by nursing staff after two (2) of two (2) patients attempted suicide by strangulation (See Tag A 386); and, the hospital failed to be responsible to ensure supervision of nursing care related to attempted suicide by strangulation and the failure of all nurses involved to complete an Occurrence Report and a Sentinel Report and to provide an assessment and documentation after an attempted suicide (See Tag A 395).
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review, document review and staff interview it was determined the hospital failed to ensure nursing staff followed policies on Occurrence Reporting and Sentinel Event Reporting involving attempted strangulation in two (2) of two (2) records reviewed (patients #1 and 4). This failure has the potential for all patients to have the ability to commit self harm or suicide by hanging or strangulation.

Findings include:

1. Review of the medical record for patient #1 revealed she was admitted on [DATE] with a diagnosis of schizoaffective disorder. On 12/30/15 at 9:30 p.m. patient #1 presented to the nursing station with a reddened neck. Registered Nurse (RN) #1, RN #2 and Licensed Practical Nurse (LPN) #1 questioned her about how her neck became red and she admitted she had just tried to strangle herself with her bra. Nurse Practitioner (NP) #1 (on call) was notified and the patient was placed on one (1) on one (1) and in a room closer to the nursing station. No assessment or vital signs were documented at the time of the incident.

2. Review of the medical record for patient #4 revealed she was admitted on [DATE] with a diagnosis of suicidal ideation. On 1/25/16 at 7:01 p.m. patient #4 was found on the bathroom floor with a sheet on the floor beside her and her neck was reddened. The patient stated, "Suicide thoughts are there all the time." NP #1 was notified and the patient was placed on one (1) on one (1). No assessment or vital signs were documented at the time of the incident.

3. Review of the Nursing Supervisor end of shift report on 12/30/15 revealed the Nursing Supervisor was notified (no time documented for notification) of the attempted strangulation on patient #1. No Occurrence Report or Sentinel Event Report was initiated by RN #1, RN #2, LPN #1, NP #1 or the Nursing Supervisor.

4. Review of the Nursing Supervisor end of shift report on 1/25/16 revealed the Nursing Supervisor was notified (no time documented for notification) of the attempted strangulation on patient #4. No Occurrence Report or Sentinel Event Report was initiated by the nursing staff or the Nursing Supervisor.

5. Review of the policy titled, "Occurrences", last revised 8/2014, states, in part: "A reportable occurrence is any event, which is not consistent with normal hospital operations or routine patient care...Events of untoward, undesirable and usually unanticipated in the care of the patients."

6. Review of the policy titled, "Sentinel Event/Near Miss", last reviewed 3/2015, revealed, in part: "A near miss is a potential for more serious consequences."

7. An interview was conducted on 3/14/16 at 11:36 a.m. with NP #1. She concurred both patient #1 and patient #4 tried to strangle themselves and stated she did not fill out an Occurrence Report or a Sentinel Event Report. When asked why she failed to report an attempted suicide to administration through the hospital's reporting system she stated, "I just never thought about it."

8. An interview was conducted with RN #1 on 3/14/16 at 3:26 p.m. When asked if she remembered patient #1 she stated, "Yes." When asked if she documented an assessment or filed an Occurrence Report concerning the attempted suicide she stated, in part (after accessing Patient #1's medical record): "I didn't document an assessment and no I didn't fill out an Occurrence Report. We notified the Nursing Supervisor about the attempted suicide."

9. An interview was conducted with LPN #1 on 3/14/16 at 3:37 p.m. When asked if she remembered patient #1 she stated, "Yes." When asked if she filed an Occurrence Report involving the attempted suicide she stated, in part: "No, I didn't. I assumed the RN's did it."

10. An interview was conducted with RN #2 on 3/14/16 at 3:44 p.m. When asked if she remembered patient #1 she stated, "Yes." When asked if she documented an assessment or filed an Occurrence Report concerning the attempted suicide she stated, in part (after accessing Patient #1's medical record): "I didn't document an assessment; she wasn't my patient. And no, I didn't fill out an Occurrence Report and I'm not sure if the supervisor was notified."

11. An interview was conducted with the Chief Executive Officer (CEO) on 3/16/16 at 9:30 a.m. When asked whose responsibility it is to read the Nursing Supervisor's end of shift report she stated, in part: "The Chief Nursing Officer reviews them and then I review them and if we have a problem we send them to the Director of Quality." When asked why no one had seen the attempted strangulation on the Nursing Supervisor report the CEO stated, in part: "I was on vacation as was the Director of Quality during the holiday season. The Chief Nursing Officer would've been responsible and it got missed."

12. An interview was conducted with the Director of Clinical Services on 3/16/16 at 10:45 a.m. When asked what her expectation of assessment and documentation on an attempted suicide would be she stated, in part: "I would expect an assessment and vital signs to be done at the time of the incident and every four (4) hours until the patient was declared stable by the physician." She further stated she would expect an Occurrence Report to be filled out on anything out of the normal in patient care. During the interview she also concurred with the above findings.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on record review and staff interview it was determined the hospital failed to ensure nursing staff completed a patient assessment and documentation of an attempted suicide on two (2) of two (2) medical records reviewed (patients #1 and 4). This failure has the potential to negatively affect the health of any patient who attempts suicide.

Findings include:

1. Review of the medical record for patient #1 revealed she was admitted on [DATE] with a diagnosis of schizoaffective disorder. On 12/30/15 at 9:30 p.m. patient #1 presented to the nursing station with a reddened neck. Registered Nurse (RN) #1, RN #2 and Licensed Practical Nurse (LPN) #1 questioned her about how her neck became red and she admitted she had just tried to strangle herself with her bra. Nurse Practitioner (NP) #1 (on call) was notified and the patient was placed on one (1) on one (1) and in a room closer to the nursing station. No assessment or vital signs were documented at the time of the incident.

2. Review of the medical record for patient #4 revealed she was admitted on [DATE] with a diagnosis of suicidal ideation. On 1/25/16 at 7:01 p.m. patient #4 was found on the bathroom floor with a sheet on the floor beside her and her neck was reddened. The patient stated, "Suicide thoughts are there all the time." NP #1 was notified and the patient was placed on one (1) on one (1). No assessment or vital signs were documented at the time of the incident.

3. An interview was conducted on 3/16/16 at 10:45 a.m. with the Director of Clinical Services. When asked what her expectation of assessment and documentation on an attempted suicide would be, she stated, in part: "I would expect an assessment and vital signs to be done at the time of the incident and every four (4) hours until the patient was declared stable by the physician." During the interview she also concurred with the above findings.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
The hospital failed to maintain a safe setting for all patients on Unit 2 B as evidenced by the presence of looping devices in fifteen (15) of fifteen (15) patient rooms (See Tag A 701).
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observation and staff interview it was determined the hospital failed to provide a safe setting for all patients as evidenced by the presence of looping devices in fifteen (15) of fifteen (15) patient rooms on Unit 2 B. This failure has the potential for all patients to have the ability to cause self harm or suicide by hanging or strangulation due to an unsafe physical environment.

Findings include:

1. During an inspection of Room 227 on Unit 2 B, conducted on 3/14/16 at 10:13 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

2. During an inspection of Room 228 on Unit 2 B, conducted on 3/14/16 at 10:20 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

3. During an inspection of Room 229 on Unit 2 B, conducted on 3/14/16 at 10:30 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

4. During an inspection of Room 230 on Unit 2 B, conducted on 3/14/16 at 10:38 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

5. During an inspection of Room 231 on Unit 2 B, conducted on 3/14/16 at 10:45 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

6. During an inspection of Room 233 on Unit 2 B, conducted on 3/14/16 at 10:50 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower valves, sprinkler heads and door hinges.

7. During an inspection of Room 234 on Unit 2 B, conducted on 3/14/16 at 10:55 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower valves, sprinkler heads and door hinges.

8. During an inspection of Room 236 on Unit 2 B, conducted on 3/14/16 at 11:05 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower valves, sprinkler heads and door hinges.

9. During an inspection of Room 237 on Unit 2 B, conducted on 3/14/16 at 11:10 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower valves, sprinkler heads and door hinges.

10. During an inspection of Room 238 on Unit 2 B, conducted on 3/14/16 at 11:20 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

11. During an inspection of Room 239 on Unit 2 B, conducted on 3/14/16 at 11:25 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

12. During an inspection of Room 240 on Unit 2 B, conducted on 3/14/16 at 11:35 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

13. During an inspection of Room 241 on Unit 2 B, conducted on 3/14/16 at 11:45 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

14. During an inspection of Room 242 on Unit 2 B, conducted on 3/14/16 at 11:50 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges

15. During an inspection of Room 243 on Unit 2 B, conducted on 3/14/16 at 11:55 a.m., the following items were identified as potential looping devices: patient beds, desk, chair, shower hoses, shower valves, sprinkler heads and door hinges.

16. On 3/14/16 at 12:05 p.m., the above findings were discussed with the Facility Maintenance Director and he agreed the issues needed to be corrected.