The hospital shall provide private rooms to meet the needs of patients and programs of the hospital. There shall be no more than four beds in each patient room in existing construction. In construction after the approval date of this rule, there may be no more than two patient beds in each room.
A. Based on document review, observation and staff interview, it was determined the facility failed to ensure there was no more than two (2) patients per room. This has the potential to affect all patients' privacy and independence within the facility.
Findings include:
A review of State code titled "Title 64 Legislative Rule, Department of Health and Human Resources, Series 59, Patient Rights At State Operated Mental Health Facilities," e-file issued 04/29/21, states in part: "15.2.3. No person shall be housed in a bedroom with more than one [1] other person. Sleeping areas shall be assigned based on the patient's need for group support, privacy, and independence."
A review of policy titled "Plan for Management of Patient Census," effective 03/22, states in part: "B. Monitoring and Reporting Patient Overflow: Internal Reporting of Census Level: The daily patient census report is compiled by the Admission Office. The Admission Department has access to each unit's patient location document and monitors the census at all times. Hospital management, including the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Nurse Managers, and the Nurse Clinical Coordinators (NCC) are notified of the hospital census on a daily basis by the Admission Office ... Evaluation of the Effectives of the Plan for Management of Patient Census: ... The Leadership of the facility will review the actions taken in anticipation of and in response to the patient census and determine if the actions taken were effective or if additional action is needed during the morning huddle.
During a tour of Unit N-1 on 5/31/23 at 3:30 p.m., the following rooms had three (3) patients each: Rooms 1210, 1211, 1214, 1232, 1236, 1240, and 1243.
During a tour of Unit N-2 on 5/31/23 at 3:45 p.m., the following rooms had three (3) patients each: Rooms 1111, 1114, 1153, 1154, and 1162.
An interview was conducted with Lead Nurse #1 on 5/31/23 at 3:45 p.m. Lead Nurse #1 concurred, "There has been three (3) beds in Rooms 1210, 1214, 1232, 1236, 1240 and 1243 for over six (6) months because of the bed crisis."
An interview was conducted with Lead Nurse #2 on 5/31/23 at 4:00 p.m. Leader Nurse #2 concurred, "There has been three (3) beds in Rooms 1111, 1114, 1153, 1154, and 1162 for months and there are and has been three (3) patients assigned to these rooms."
An interview was conducted with the Chief Executive Officer on 06/01/23 at 8:43 a.m. They had been asked on 05/31/23 to get the number of forthwith patients for the past year. They stated they had two (2) forthwith patients this year (2023).
B. Based on document review, observation and staff interview, it was determined the facility failed to follow state code regarding providing a window in each bedroom and ample closet storage and drawer space to store clothing, hygiene products and personal items. This has the potential to affect all patients' privacy and independence within the facility.
Findings include:
15.2.4 A review of State code titled "Title 64 Legislative Rule, Department of Health and Human Resources, Series 59, Patient Rights At State Operated Mental Health Facilities," e-file issued 04/29/21, states in part: "All bedrooms shall have an outside window be above ground level and provide adequate space for patient privacy."
15.2.5 A review of State code titled "Title 64 Legislative Rule, Department of Health and Human Resources, Series 59, Patient Rights At State Operated Mental Health Facilities," e-file issued 04/29/21, states in part: "Patients shall have ample closet and drawer space shall be provided for storing clothes, personal hygiene articles, and other personal property."
A review of policy titled "Plan for Management of Patient Census," effective 03/22, states in part: "B. Monitoring and Reporting Patient Overflow: Internal Reporting of Census Level: The daily patient census report is compiled by the Admission Office. The Admission Department has access to each unit's patient location document and monitors the census at all times. Hospital management, including the Chief Executive Officer, Chief Medical Officer, Chief Nursing Officer, Nurse Managers, and the Nurse Clinical Coordinators (NCC) are notified of the hospital census on a daily basis by the Admission Office ... Evaluation of the Effectives of the Plan for Management of Patient Census: ... The Leadership of the facility will review the actions taken in anticipation of and in response to the patient census and determine if the actions taken were effective or if additional action is needed during the morning huddle.
During a tour of Unit E on 5/31/23 at 3:45 p.m., it was found that one (1) visitation room was being used as a bedroom for one (1) patient. There were no windows in the bedroom and no closets or drawers made available to the patient to store personal items.
An interview was conducted with Lead Nurses #1 and 2 on 5/31/23 at 3:45 p.m. and they concurred the room was being used as bedroom for one (1) patient for months due to the bed crisis at the hospital.
An interview was conducted with the Chief Executive Officer (CEO) on 06/01/23 at 8:43 a.m. They had been asked to get the number of forthwith patient for the past year on 05/31/23. They informed me this morning at 8:43 a.m. that they had two (2) forthwith patients this year (2023).
Process Change:
1. Blocked beds will become an agenda item and be reviewed at regularly scheduled leadership huddle meetings (business days) to determine beds, if any, that can be released.
2. Sharpe Hospital will develop a No Admission/Full Divert Policy establishing criteria for denial, notification of denial, wait list process, and communication process (inclusive of, but not limited to: Law Enforcement, Mental Health Centers, and Mental Hygiene Commissioners) for periods when it is unable to admit patients under West Virginia State Code \'a7 27-5-1, et. seq.
3. Patients unable to be diverted or denied admission due to bedding limitations will be tracked and the referring Comprehensive Behavioral Health Center will be contacted when a bed is available, and an admission will be scheduled.
4. Sharpe Hospital will discharge all patients deemed to meet clinical discharge criteria to ensure all patient's rooms will be occupied by no more than two patients, all patients that are admitted are afforded a room with a window, ample closet, and drawer space for storing clothes, personal hygiene articles and other personal property and provide adequate space for patient privacy.
Education:
1. Senior leadership, including the Chief Medical Officer (CMO), Chief Nursing Officer (CNO), Chief Financial Officer (CFO) and Director of Facilities will be educated on the process changes by the Chief Executive Officer (CEO) and /or the CEO's designee.
2. The CMO will educate the Medical Staff, the CNO will educate the NCC's, the CFO will educate the Admission Office and the Director of Facilities will educate the Maintenance Department regarding the above process changes as it applies to each department.
3. Medical and Clinical staff will be educated by the CEO and/or the CEO's designee on the newly developed No Admission/Full Divert Policy criteria, maintenance of a wait list process and communication process requirements to the community providers. Admission staff will be educated by the CFO and/or the CFO's designee on the newly developed No Admission /Full Divert Policy criteria, maintenance of a wait list process and communication process requirements to the community providers.
4. Education regarding Discharge Planning will be provided to treatment teams by the CMO and/or the CMO's designee.
5. Sharpe Hospital will develop an EMTALA Policy and post appropriate signage by the CEO and/or the CEO's designee.
6. Medical Staff, Nurse Clinical Supervisors, Administrators on-call, and admissions staff will be educated on the EMTALA Policy by the CEO and/or the CEO's designee.
Monitoring:
1. The admissions office will monitor the number of times a patient bedroom is utilized for more than two patients or a room that is not a patient bedroom is utilized as a patient bedroom and report their findings to the Quality Council committee and the CQI committee for 3 months and the Governing Board at the regularly scheduled meeting for one quarter.
Responsible Person: Chief Executive Officer