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.

WILLIAM R SHARPE, JR HOSPITAL 936 SHARPE HOSPITAL ROAD WESTON, WV 26452 Aug. 19, 2020
VIOLATION: Director of Psychiatric Nursing Tag No: A1700
Based on interviews and review of documents it was revealed the hospital has no designated qualified Director of Nursing (DON), Interim DON, Chief Nursing Officer (CNO) or Interim CNO. This failure to provide a designated leader in nursing places all patients at risk for harm due to inconsistent care.

Findings included:

In an interview conducted with the Chief Executive Officer (CEO) on 8/17/20 at 4:00 p.m. he stated the Assistant Chief Nursing Officer (ACNO) acts as the CNO. He stated the hospital is attempting to get the pay grade increased for the CNO position. The CEO agreed the CNO fulfills a unique need in the hospital. He agreed that without an interim CNO there is no guarantee the CNO duties are being performed.

In an interview conducted with the ACNO on 8/18/20 at 10:00 a.m. he stated he has had no training for the ACNO position. He stated he is not the official Interim CNO. He stated he just "steps up" because the position is vacant. He stated he had not been asked to be the ACNO until "..the last couple days." The ACNO stated he could not guarantee the jobs are being done by the Interim CNO.

In a follow-up interview conducted with the ACNO on 8/19/20 at 1:33 p.m. he stated he would say he is the
Interim CNO by default. He stated he received a ACNO job description in September 2019 but not an Interim CNO job description. He stated he signed a new job description which included Interim CNO verbiage on 8/18/20. He stated this was after his interview with the State surveyors.

A document titled "William R. Sharpe, Jr. Hospital Functional Job Description Assistant Chief Nursing Officer" was reviewed. The prepared date on the document was 4/6/2011. The first document was signed by the ACNO on 1/10/19. A second document with the same title which had the same content (also dated as prepared 4/6/2011) contained an additional sentence in the document. A review of this addition revealed it states, "In the absence of the Chief Nursing Officer, the ACNO assumes the responsibilities of the CNO and direction of the Nursing Department." The second document was signed by the ACNO on 8/17/20.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on interviews and review of documents it was revealed the hospital has no designated qualified Director of Nursing (DON), Interim DON, Chief Nursing Officer (CNO) or Interim CNO. This failure to provide a designated leader in nursing places all patients at risk for harm due to inconsistent care.

Findings include:

In an interview conducted with the Chief Executive Officer (CEO) on 8/17/20 at 4:00 p.m. he stated the Assistant Chief Nursing Officer (ACNO) acts as the CNO. He stated the hospital is attempting to get the pay grade increased for the CNO position. The CEO agreed the CNO fulfills a unique need in the hospital. He agreed that without an interim CNO there is no guarantee the CNO duties are being performed.

In an interview conducted with the ACNO on 8/18/20 at 10:00 a.m. he stated he has had no training for the ACNO position. He stated he is not the official Interim CNO. He stated he just "steps up" because the position is vacant. He stated he had not been asked to be the ACNO until "..the last couple days." The ACNO stated he could not guarantee the jobs are being done by the Interim CNO.

In a follow-up interview conducted with the ACNO on 8/19/20 at 1:33 p.m. he stated he would say he is the
Interim CNO by default. He stated he received a ACNO job description in September 2019 but not an Interim CNO job description. He stated he signed a new job description which included Interim CNO verbiage on 8/18/20. He stated this was after his interview with the State surveyors.

A document titled "William R. Sharpe, Jr. Hospital Functional Job Description Assistant Chief Nursing Officer" was reviewed. The prepared date on the document was 4/6/2011. The first document was signed by the ACNO on 1/10/19. A second document with the same title which had the same content (also dated as prepared 4/6/2011) contained an additional sentence in the document. A review of this addition revealed it states, "In the absence of the Chief Nursing Officer, the ACNO assumes the responsibilities of the CNO and direction of the Nursing Department." The second document was signed by the ACNO on 8/17/20.
VIOLATION: ORGANIZATION OF NURSING SERVICES Tag No: A0386
Based on interviews and review of documents it was revealed the hospital has no designated qualified Director of Nursing (DON), Interim DON, Chief Nursing Officer (CNO) or Interim CNO. This failure to provide a designated leader in nursing places all patients at risk for harm due to inconsistent care.

Findings include:

In an interview conducted with the Chief Executive Officer (CEO) on 8/17/20 at 4:00 p.m. he stated the Assistant Chief Nursing Officer (ACNO) acts as the CNO. He stated the hospital is attempting to get the pay grade increased for the CNO position. The CEO agreed the CNO fulfills a unique need in the hospital. He agreed that without an interim CNO there is no guarantee the CNO duties are being performed.

In an interview conducted with the ACNO on 8/18/20 at 10:00 a.m. he stated he has had no training for the ACNO position. He stated he is not the official Interim CNO. He stated he just "steps up" because the position is vacant. He stated he had not been asked to be the ACNO until "..the last couple days." The ACNO stated he could not guarantee the jobs are being done by the Interim CNO.

In a follow-up interview conducted with the ACNO on 8/19/20 at 1:33 p.m. he stated he would say he is the
Interim CNO by default. He stated he received a ACNO job description in September 2019 but not an Interim CNO job description. He stated he signed a new job description which included Interim CNO verbiage on 8/18/20. He stated this was after his interview with the State surveyors.

A document titled "William R. Sharpe, Jr. Hospital Functional Job Description Assistant Chief Nursing Officer" was reviewed. The prepared date on the document was 4/6/2011. The first document was signed by the ACNO on 1/10/19. A second document with the same title which had the same content (also dated as prepared 4/6/2011) contained an additional sentence in the document. A review of this addition revealed it states, "In the absence of the Chief Nursing Officer, the ACNO assumes the responsibilities of the CNO and direction of the Nursing Department." The second document was signed by the ACNO on 8/17/20.