Weirton Medical Center, Inc.

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 40269 Based on document review, medical record review, and interviews, it was determined the facility failed to follow policies and procedures for documenting post fall assessments in two (2) out of ten (10) patients reviewed, patient 1 and 3. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled, “Fall Prevention,” last revised 08/01/24. The policy states in part, “...POST- FALL GUIDELINES: 1. In the event of a fall, the RN is to perform an assessment of the patient prior to staff assisting patient back to bed. The unit manager or Administrative Supervisor may conduct a safety huddle with the assigned nurse. The assessment may include, but is not limited to the following: A. Vital signs. B. Neurological and musculoskeletal assessment C. Mobility D. Presence of pain. E. Obvious injury or deformity. F. Presence of head injury. 2. If the outcome of the assessment indicates potential head or neck injury, fracture or the fall was unwitnessed, initiate a rapid response fall and follow rapid response policy before moving the patient. 3. Documentation in the EMR should be completed under the Post Fall Assessment. should occur in the EMR. NOTE: if the fall occurs in a department that does not use the EMR, documentation of the fall is to be done in the nurse’s notes. The documentation is to include a report of the fall, physical assessment findings, immediate care and notification of the attending physician and family/responsible party, if applicable.) The EMR Post Fall documentation may include the following: A. Date and Time of fall B. Description of fall event C. Fall related injury, if any D. Fall assisted by staff E. Immediate care provided F. Provider notified / orders received G. Family notification H. Fall risk reassessment documented I. Fall risk prior to fall J. Precautions in place at time of fall ...” A review was conducted of the facility incident log for falls in the past three (3) weeks. Two (2) falls were listed on the log for the ED, patient 1 and patient 3. A review was conducted of an “Event Report” for patient 1. The event is dated 6/25/26 at 6:00 a.m. and states in part, “...Event Description: Pt [patient] returned from CT [computed tomography] with CT tech [technician]. I was outside the room and noted that both side rails were up in position. Earlier in shift I had leaned on the side rail and it collapsed under my weight. I was in another room when I heard that patient was on the floor (I didn’t hear [him/her] fall). Pt was placed in C-collar and backboard and placed back in bed. CT head was completed. Physician and charge RN were notified ...” A review was conducted of an “Event Report” for patient 3. The event is dated 6/20/26 at 10:20 p.m. and states in part, “...Event Description: Pt [patient] was in room 4 [four] in [his/her] bed with both side rails up, cardiac monitor, BP [blood pressure] cuff, and pulse ox [oximeter] on, call light in reach on siderail. While staff was not in room with pt, pt crawled out the bottom of the bed, ripped of cardiac monitor leads, pulse ox and BP cuff and tried to get up from bed. Pt was unsteady on feet, started to fall backwards, attempted to catch [him/herself] with wall but unable to and fell back onto [his/her] buttocks on the floor. Witnessed by RN [name], pt did not strike head or lose consciousness. Pt alert and oriented at this time x 4 [times four], denies pain or complaints from fall. Pt then ambulatory to bathroom with RN to urinate. VS [vital signs] stable. [physician] aware. Pt reassessed frequently and again asked at 0047 [12:47 a.m.] while assisting to bathroom if any pain from fall and denies. [Physician] aware.” A medical record review was conducted for patient 1. The patient arrived to the facility’s Emergency Department (ED) via Emergency Medical Services (EMS) on 06/25/26 at 5:10 a.m. for urology services due to urinary retention, to place a urinary catheter. The patient was noted to be confused and disoriented, and was placed on fall precautions. The patient was evaluated by urology services, and was to be transferred to the Operating Room (OR) for operative cystoscopy with catheter placement. An “ED Provider Note” by staff 5 states in part, “...Medical Decision Making MDM:...While awaiting arrival of the urologist and transfer to the operating room, the patient experienced an in-hospital fall from the emergency department stretcher at approximately 0640 [6:40 a.m.] I evaluated the patient immediately following the event. At that time, there was no apparent acute neurologic deterioration compared with the patient’s baseline examination. The patient has underlying dementia with chronic baseline confusion, but remained able to follow simple commands consistent with his initial evaluation. Pupils were equal and reactive bilaterally, there was no facial asymmetry, motor strength was 5/5 [five out of five] throughout, sensation was grossly intact, and there was no focal neurologic deficit identified on examination. No cervical spine tenderness or visible external head trauma was appreciated. A cervical collar was placed, and CT [computed tomography] imaging of the head and cervical spine was ordered immediately given the patient’s advanced age, mechanism of injury, and inability to reliably exclude intracranial injury on clinical examination because of baseline cognitive impairment. While reviewing the CT images before the finalized radiology interpretation, I identified findings concerning for possible intracranial hemorrhage and immediately communicated these concerns to both the urology and inpatient medicine teams. The finalized CT head subsequently demonstrated multiple acute intracranial hemorrhagic abnormalities, including acute left parafalcine and tentorial subdural hematomas with associated mass effect and mild rightward midline shift, a small acute left basal ganglia intraparenchymal hemorrhage, and a subacute left temporoparietal subdural hematoma with superimposed acute hemorrhage. These findings significantly altered the patient’s clinical status and required urgent neurosurgical evaluation. The imaging does not establish the timing or mechanism of each hemorrhagic finding, particularly in the presence of both acute and subacute components, and correlation with the overall clinical history is required...” The patient underwent the scheduled procedure, and a urinary catheter was placed. The patient was admitted to the Intensive Care Unit (ICU) and arrangements were started to transfer the patient to a higher level of care, however, the patient ’ s family decided to not pursue further care, and have the patient transferred back to Hospice care at a Hospice House. The patient left the facility via ambulance for Hospice on 06/25/26 at 2:00 p.m. May it be noted, there is no nursing documentation in the medical record related to the patient’s fall. A medical record review was conducted for patient 3. The patient presented to the facility ED on 06/20/26 at 9:25 p.m. via EMS after excessive drinking, lethargy, and altered mental status. The patient was given three (3) liters of fluid, and was awake, alert, and oriented, and stable for discharge home on 06/21/26 at 6:42 a.m. May it be noted, there is no nursing documentation in the medical record related to the patient having a fall. A telephone interview was conducted with staff 3 on 07/13/26 at 9:00 p.m. Regarding patient 1, staff 3 states, “I remember the patient, I had done [his/her] triage. [He/she] came here for Urology from Wheeling. I put the patient on fall precautions, as we usually put all elderly patients on fall precautions in the emergency department. Fall precautions include bed rails up, grippy socks, and call light in reach. I was just the triage nurse, so then I transitioned to the other RN. I did not assist after the patient fell. After the fact, we had a staff meeting and talked about the mattress on the bed was incorrect, and how to identify that in the future.” A telephone interview was conducted with staff 4 on 07/13/26 at 9:05 p.m. Regarding patient 1, staff 4 states, “The patient had gone to CAT [CT] scan. When [he/she] came back from CAT scan the tech [radiology technician] didn’t lock the side rails. You had to pull very hard to get the side rails to lock in place. One [1] side rail collapsed, and the patient fell on the floor. We found [him/her] lying on the floor. We put a back board under [him/her] and put a c-collar on [him/her] and sent [him/her] for a CT. The patient was very demented at baseline, and was still acting the same. I documented everything in an incident report and a nurse’s note in the chart, in a free text note. The origami note for the incident reporting would be attached to the patient’s chart. After the fact, we had a staff meeting. We discussed that it is important that we have the right mattress on the right stretcher, and to make sure the side rails click into place. The documentation was in a free text note in the chart. That’s how we usually document a fall.” A telephone interview was conducted with staff 5 on 07/13/26 at 9:45 p.m. Regarding patient 1, staff 5 states, “The patient was boarded in the ED, waiting to be transferred upstairs. I was in the staff area, and we heard a thump. All of us ran over there, and the patient was on the floor. We put a c-collar on the patient, and did a neuro [neurological] exam, the patient was at [his/her] baseline. We put a backboard under the patient, and ordered a CT of the head and neck. I did a neuro exam again, and it was the same. There were some concerns on the CT. There were potential bleeding concerns. Again, I did a neuro exam and it was still the same. By the time the final results came back, [he/she] wasn’t in the ED anymore. I communicated the results to the inpatient team. I helped them call the MARS line to initiate tertiary transfer. I didn’t know what happened after that, as the patient was no longer in the ED and I was no longer involved in [his/her] care. Most elderly patients are placed on fall precautions. There was some type of lapse in this case, there was potentially a problem with the bed, and we were unsure if the side rail collapsed or the patient climbed over the rails. We really don’t see falls that often in the ED.” An interview was conducted on 7/13/26 at 3:43 p.m. with Staff 1. Regarding patient 1, staff 1 states, “I reviewed the incident report about the patient falling. There was no documentation from nursing that the patient fell. I can’t speak as to why there was no documentation. There was no vital sign documentation from the ED after the fall either. The patient might not have been on a monitor. When the incident report was completed, I got an automatic email from the instant reporting system. I talked to the nurse that morning but [he/she] was already done for the day. I told [him/her] next time to document in the chart. I didn’t feel it appropriate for [him/her] to go back and document at this point. After this incident, we determined the wrong mattress was on the bed frame, so you had to pull the side rail harder to get it to lock. The mattress on that bed has changed. We had a staff meeting and reviewed how to determine if the wrong mattress is on the bed frame so it doesn’t happen in the future.” After reviewing documentation, staff 1 confirmed there was no documentation in patient 3 ’ s medical record related to a fall, just an incident report.”

“PATIENT RIGHTS: REVIEW OF GRIEVANCES CFR(s): 482.13(a)(2) [The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance.] The hospital’s governing body must approve and be responsible for the effective operation of the grievance process, and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. This Standard is not met as evidenced by: 43434 Based on medical record review, policy review and staff interview the facility failed to follow their complaint and grievance policy. In one (1) grievance not investigated by the facility (patient 1). This failure has the potential to effect all patients/patient representatives who file a complaint/grievance at the facility. Findings: A policy titled “Patient Care Manual, Subject: PATIENT COMPLAINTS AND GRIEVANCE” revised 8/24, states in part, “DEPARTMENT: hospital wide. POLICY: The hospital maintains a system for receiving and responding to patient and family complaints and grievances regarding hospital operations, quality of care, and safety in accordance with the following guidelines...RESPONSIBILITIES: All personnel are responsible for documenting a patient and or their families concerns and instinct instituting this complaint and grievance process...All verbal or written complaints about abuse, neglect, patient harm, or hospital compliance with CMS requirements are to be considered grievance for the purpose of these requirements. Whenever the patient or patient’s representative requests their complaint be handled as a formal, complaint or grievance, or when the patient request a response, then the complaint is a grievance and all requirements apply. GUIDELINES: III. Regardless of the source grievances should be referred to the Quality and Service Excellence Guest Relations Coordinator who will assist with the documentation of their grievance and forward to the appropriate Department Director for investigation and resolution...” A policy titled “SUBJECT: RIGHTS AND RESPONSIBILITIES OF PATIENTS”, states in part, “Policy: WVU Medicine/Weirton Medical Center (WMCH) believes that all patients have the right to be involved and participate in his or her care and treatment decisions, and that as an active participant in their care, that they have certain responsibilities. PURPOSE: Individual rights during the provision of care and services and to communicate expectations of patient responsibilities for participating in their care. SCOPE: Describes the process established to support the rights of all patients throughout the continuum of care offered by WVU Medicine/WMCH ...INDIVIDUAL CONCERNS: You have the right to complain about your care, accommodations or treatment without fear of retaliation or denial of treatment. If a problem occurs, please refer the complaint to your patient care provider. If the matter is not resolved, contact the manager for your nursing unit or department. You can do this on Monday through Friday between 8:00 AM and 4:00 PM by calling the hospital operator and asking for the director for your nursing unit or department. Between 4:00 PM and 8:00 AM on weekends, weekdays, or 24 hours a day on weekends and holidays, call the hospital operator and ask for the administrative supervisor. If the problem remains Unresolved, Please contact the Director of Performance Improvement at 304-797-6004, Monday through Friday, between 9:00 a.m. and 5:00 p.m... You may also contact the administrator at 304-797-6117, Monday through Friday, between 9:00 a.m. and 5:00 p.m...” An interview was conducted on 11/19/25 at 12:30 p.m. with staff 13. Staff 13 stated, “I don’t remember the first time [family member] told me about their concerns. It might have been 9/18/25 or 9/19/25. [He/She] called to make me aware of how bad [he/she] felt staffing was on the unit. [He/She] said you don’t have enough staff to feed people. [He/She] explained that [his/her] [family member] takes a long time to feed and you can’t rush [him/her]. [He/She] told me that [his/her] [family member] had aspirated on unit 8 and had to be moved to CCU. I explained I wasn’t aware of that. [He/She] stated that [he/she] thinks that staff feed [him/her] too fast and it caused [him/her] to aspirate. [He/She] said that I needed to look into that to make sure they didn’t feed [him/her] too fast. You need to check it out, the staffing and aspiration is what [he/she] was talking about. I told her I would do my best but it’s hard to prove that someone fed [him/her] too fast. You can’t really prove that. [He/She] said I’m working from home now and I could bring my laptop and work at the hospital if you could work on me getting paid for it. I could make sure [he/she] was fed appropriately. I told [him/her] that there is no reason for that. I will talk to the director of the unit to see what happened. I spoke with [staff 16] and explained to [him/her] that the [family member] had made accusations that the aspiration of the patient was because staff fed the patient too fast. [Staff 16] stated that [he/she] had talked with [staff 9] and that the doctors had said it was medical reasons. I spoke with [staff 1] and [he/she] did not feel it was because someone fed the patient too fast. I never followed back up with [staff 16] about it and I didn’t document it or investigate it... Issues with the aspiration and [his/her] accusations about staff fell off my radar. I did not document the conversation, nor did I do an investigation into the allegations. I didn’t provide [him/her] with a response”. An untitled document was reviewed that reflected grievances from 4/07/25 through 11/07/25. There was no evidence of a complaint or grievance filed on behalf of patient 1. A request was made for documention of the interaction with the [family member] that complained and the report or investigation of the complaint. Staff 13 stated nothing was documented or investigated.”

“COMPLIANCE WITH 489.24 CFR(s): 489.20(l) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to comply with §489.24. This Standard is not met as evidenced by: 46199 Based on review of facility documents, medical records (MR), and staff interviews it was determined the facility failed to comply with 489.24 by failing to provide an appropriate medical screening examination (MSE) to rule out an emergency medical condition (EMC) (See tag; A-2406) and the facility failed to provide an appropriate transfer (See tag; A-2409). Cross Reference: 489.24 (a) & 489.24 (c) Medical Screening Examination §489.24 (e) Appropriate Transfer.”

“MEDICAL SCREENING EXAM CFR(s): 489.24(a) & 489.24(c) (a) Applicability of provisions of this section. (1) In the case of a hospital that has an emergency department, if an individual (whether or not eligible for Medicare benefits and regardless of ability to pay) “comes to the emergency department”, as defined in paragraph (b) of this section, the hospital must- (i) Provide an appropriate medical screening examination within the capability of the hospital’s emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. The examination must be conducted by an individual(s) who is determined qualified by hospital bylaws or rules and regulations and who meets the requirements of §482.55 of this chapter concerning emergency services personnel and direction; and (ii) If an emergency medical condition is determined to exist, provide any necessary stabilizing treatment, as defined in paragraph (d) of this section, or an appropriate transfer as defined in paragraph (e) of this section. If the hospital admits the individual as an inpatient for further treatment, the hospital’s obligation under this section ends, as specified in paragraph (d)(2) of this section. (2)(i) When a waiver has been issued in accordance with section 1135 of the Act that includes a waiver under section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual’s source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will continue in effect until the termination of the applicable declaration of a public health emergency, as provided under section 1135(e)(1)(B) of the Act. (c) Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. This Standard is not met as evidenced by: 46199 Based on review of facility documents, medical records (MR), and staff interviews it was determined that the facility failed to provide an appropriate medical screening examination to one (1) of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Care of the Suicidal Patient”, reviewed 10/22. The policy has a section titled “Policy” which states “Weirton Medical Center is committed to providing a safe environment for patients, visitors, and employees. Early identification of patients at risk for suicide is a first step in providing care and intervention...5. When the patient presents to the Emergency Department it is the responsibility of the physician to evaluate the patient.” A policy was reviewed titled “Emergency Medical Treatment and Active Labor Act (EMTALA)”, reviewed 8/24. The policy has a section titled “Policy” which states, in part, “Weirton Medical Center will treat all patients regardless of their ability or inability to pay. To this extent it is required that: ...all patients who come to a dedicated Emergency Department will have an emergency screening exam to determine if they are experiencing an emergency condition ...” A medical record review was conducted for Patient #1. Patient #1 presented to the Emergency Department (ED) on 9/24/24 complaining of suicidal ideation, with no plan. An entry in the medical record titled “ED Note - Physician” completed by Staff #2 on 9/24/24 at 9:23 p.m. states, in part, “History of Present Illness: [Patient #1] comes to the emergency room complaining of not being on [his/her] right medications...Patient states [he/she] has suicidal thoughts but not actively suicidal at the same time. Patient said that [he/she] has attempted in the past taking too many pills...” The entry also contains a section titled “Medical Decision Making” which states, in part “...Patient cleared from a medical standpoint from the emergency room for psych management. Will continue to monitor Patient emergency room while setting up transfer.” A document without a title states in part, (Patient 1’s name). Presenting problem SI [suicidal ideations] Diagnosis ...SI, depression. Treatment date: psych clear. Proposed discharge plan: to psych facility. A document without a title states in part, (Patient 1’s name). Clinical Diagnosis: Suicidal Ideations. A review of a nursing note on 09/24/24 and electronically signed at 10:17 p.m. shows that five (5) inpatient facilities were contacted for transfer and the facility was still awaiting an inpatient psychiatric transfer at the time of discharge. A review of ED discharge instructions included education materials on “Helping someone with suicide”. It should be noted there was no assessment for capacity, psychological evaluation or a suicide risk assessment in the medical record. An interview was conducted with Staff #2 on 9/26/24 at 12:54 p.m. Staff #2 was asked about their interaction with Patient #1. Staff #2 stated in part. The Patient did not want to go to a facility that was a long distance from here. [His/Her] suicidal ideations were just wanting medications. An interview was conducted with Staff #5 on 9/27/24 at 10:05a.m. Staff #5 was asked about triaging Patient #1. Staff #5 stated, “[He/She] was super nice. [He/She] said ‘I’ve been feeling down, I need to get back on my meds.’ [He/She] wanted to go to [another state] and said they were thinking about hurting [himself/herself] sometimes.” Staff #5 was asked what actions were taken once triage was completed. Staff #5 stated, “[He/She] was placed in the psych room, nurse came and took all of [his/her] belongings and the doctor was told that the Patient was in the room.””

“APPROPRIATE TRANSFER CFR(s): 489.24(e)(1)-(2) (1) General If an individual at a hospital has an emergency medical condition that has not been stabilized (as defined in paragraph (b) of this section), the hospital may not transfer the individual unless - (i) The transfer is an appropriate transfer (within the meaning of paragraph (e)(2) of this section); and (ii)(A) The individual (or a legally responsible person acting on the individual’s behalf) requests the transfer, after being informed of the hospital’s obligations under this section and of the risk of transfer. The request must be in writing and indicate the reasons for the request as well as indicate that he or she is aware of the risks and benefits of the transfer. (B) A physician (within the meaning of section 1861(r)(1) of the Act) has signed a certification that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at another medical facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the woman or the unborn child, from being transferred. The certification must contain a summary of the risks and benefits upon which it is based; or (C) If a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person (as determined by the hospital in its bylaws or rules and regulations) has signed a certification described in paragraph (e)(1)(ii)(B) of this section after a physician (as defined in section 1861(r)(1) of the Act) in consultation with the qualified medical person, agrees with the certification and subsequently countersigns the certification. The certification must contain a summary of the risks and benefits upon which it is based. (2) A transfer to another medical facility will be appropriate only in those cases in which - (i) The transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual’s health and, in the case of a woman in labor, the health of the unborn child; (ii) The receiving facility (A) Has available space and qualified personnel for the treatment of the individual; and (B) Has agreed to accept transfer of the individual and to provide appropriate medical treatment. (iii) The transferring hospital sends to the receiving facility all medical records (or copies thereof) related to the emergency condition which the individual has presented that are available at the time of the transfer, including available history, records related to the individual’s emergency medical condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or telephone reports of the studies, treatment provided, results of any tests and the informed written consent or certification (or copy thereof) required under paragraph (e)(1)(ii) of this section, and the name and address of any on-call physician (described in paragraph (g) of this section) who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment. Other records (e.g., test results not yet available or historical records not readily available from the hospital’s files) must be sent as soon as practicable after transfer; and (iv) The transfer is effected through qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transfer. This Standard is not met as evidenced by: 46199 Based on review of facility documents, medical records (MR), and staff interviews it was determined that the facility failed to provide an appropriate transfer to one (1) of twenty (20) patients, Patient #1. This failure has the potential to negatively impact all patients receiving care at the facility. Findings include: A policy was reviewed titled “Emergency Medical Treatment and Active Labor Act (EMTALA)”, reviewed 8/24. The policy has a section titled “Policy” which states, in part, “Weirton Medical Center will treat all patients regardless of their ability or inability to pay. To this extent it is required that: ...all patients who come to a dedicated Emergency Department will have an emergency screening exam to determine if they are experiencing an emergency condition; patients experiencing an emergency medical condition will be stabilized prior to transfer; and any transfers will occur only after the receiving hospital has agreed to accept the patient and the patient (or surrogate decision maker) has agreed to the transfer.” A medical record review was conducted for Patient #1. Patient #1 presented to the Emergency Department (ED) on 9/24/24 complaining of suicidal ideation, with no plan. An entry in the medical record titled “ED Note - Physician” completed by Staff #2 on 9/24/24 at 9:23 p.m. states, in part, “History of Present Illness: [Patient #1] comes to the emergency room complaining of not being on [his/her] right medications...Patient states [he/she] has suicidal thoughts but not actively suicidal at the same time. Patient said that [he/she] has attempted in the past taking too many pills...” This entry also contains a section titled “Medical Decision Making” which states, in part “...Patient main stable emergency room nontoxic in no acute distress not giving any trouble. Patient cleared from a medical standpoint from the emergency room for psych management. Will continue to monitor Patient emergency room while setting up transfer.” It should be noted that there is no documentation that the receiving facility was notified of the Patient, that report was given or the receiving facility was given the Patient’s medical record. An interview was conducted with Staff #2 on 9/26/24 at 12:54 p.m. Staff #2 was asked about their interaction with Patient #1. Staff #2 stated, “The Patient did not want to go to a facility that was a long distance from here. [His/Her] suicidal ideations were just wanting medications.” Staff #2 was asked why a transfer was not completed for Patient #1. Staff #2 stated, “[He/She] called [his/her] [parent] and [parent] came to the Emergency Room. The Patient could have been transferred but [Patient #1] and [parent] were very pleased with the plan to follow up at another facility. An interview was conducted with Staff #3 on 9/26/24 at 1:09p.m. Staff #8 was also present during this interview. Staff #3 was asked about their interaction with Patient #1. Staff #3 stated, “We started the process for transferring the patient to a psychiatric facility. We contacted several different facilities that evening,” Staff #3 was asked why Patient #1 was not transferred to another facility. Staff #3 stated, “[His/Her] [parent] came to the emergency room. and [his/her] [parent] said they would take the Patient and get follow up care at another facility.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 43434 Based on documentation review and staff interviews the facility failed to document all incidents of personal hygiene care and repositioning of the Patient. This failure has the potential to affect all Patients within the hospital. Findings: A medical record review was conducted for Patient #1. Patient#1 presented to Emergency Department (ED) via Emergency Medical Services (EMS) from a local nursing facility. It was reported that the Patient was having episodes of breakthrough seizures. The Patient has a history of seizures and anoxic brain injury. The patient has also suffered two (2) cardiac arrests and has a surgical procedure (S/P) tracheostomy. Upon arriving at the facility, the Patient was oxygenating appropriately as evidenced by blood gases results. Chest x-rays were negative for any signs of pneumonia. Patient #1 was given a gram of Keppre in the ED. Urinalysis testing was indicative of urinary tract infection (UTI) and given Rocephin. Patient #1 is nonverbal and is diagnosed with Congestive Heart Failure (CHF), Edema, Hypertension, Myocardial Infraction and Urinary tract infection. Patient #1 was Admit on 5/28/24 at 7:26 p.m., for further evaluation. The Patient received a consultation to neurology on 5/29/24, for breakthrough seizures, and possible medication adjustment. CT scan was completed on 6/18/24, and reflected no intracranial hemorrhage, mass effect, or evidence of large acute infraction. The Patient received the following medical services: Arterial Blood Gas Test (ABG), Blood Grouping, Antibody screen, Basic Metabolic Panel (BMP), Comprehensive Metabolic Panel (CMP), Glucose Tolerance Test, Lactic Acid Test, Methemoglobin Blood Test, Computerized Tomography (CT), abdomen, pelvis and brain, Abdomen and chest x-ray, Respiratory Therapy, Wound Care, Esophagogastroduodenoscopy (EGD), Occupational evaluation and Physical Therapy evaluation. An order for Wound care was started on 5/29/24. The order was for wound care every week, foam, change dressing PRN, apply convafoam dressing to bilat heels, 7 days and prn. The medical record supported that the patient did not have pressure ulcers or any breakdown of the skin. Wound care was provided as a preventative measure due to the patient being bed fast and immobile. Wound care unit assessment notes completed by (Employee #9) and (Employee #13) for the days of 5/28/24, 6/13/24 and 6/20/24, reflect that Patient #1 had no skin breakdown, bottom was good. Preventive recommendations for foam for the bottom and heel boot for patient, change dressing as needed and apply barrier cream was documented. Nursing documentation was reviewed for Patient #1, “Activities of Daily LIVING Report,”. The Patient was admitted on May 28, 2024. The documentation was not consistent, with missing shift documentation. It was found that there were twenty-two (22) documented combined episodes of personal care provided. These findings included bathing, brief changes, dressing, foley care and repositioning of the Patient and were documented as complete on the following dates and times. 5/29/24 at 7:15 a.m., 6/2/24 at 9:42 a.m.,6/7/24 at 7:30 a.m.& 8:31 p.m., 6/8/24 at 8:45 a.m., 6/12/24 5:28 p.m. & 1:11 p.m., 6/13/24 at 9:34 a.m. and 1:30 p.m., 6/14/24 at 9:45 a.m. & 2:34 p.m., 6/15/24 at 9:03 a.m. & 7:33 p.m., 6/16/24 at 10:32 a.m., 6/17/24 at 7:00 a.m., 6/18/24 at 10:27 a.m., 6/19/24 at 11:09 a.m. & 3:20 p.m., 6/20/24 at 6:45 a.m., 6/21/24 at 11:13 a.m., 6/22/24 at 12:00 p.m., and 6/24/24 at 3:22 p.m. An interview was conducted with Employee #2 on 07/22/24 at 1:05 p.m. “Patient #1 was nonverbal and non-ambulatory, just blinks the eyes, can’t talk, can’t move lower extremities, questionable seizure, admitted from a local Nursing Home and transferred to the facility by EMS.” Employee # 2 was asked if there were any signs of brain activity? “No at all”. Employee #2 stated that Patient #1 did not have bed sores. Employee #2 did rounds, assessed Patient #1. Patient #1 ordered special mattress with air pump and heels boots for feet. Employee #2 states that an admission nurse would have done the full assessment, regularly if patients have bed sores, staff take pictures, measures and documents and call wound care. Employee # 2 claims that Patient #1’s spouse complains about the Patients’ eyes had (crust), needs a bath, so staff took care of the bath, Employee #2 believes that patient #1 had eye infection and got eye drops that would cause some drainage. Employee #2 doesn’t remember any issues related to water in the patient’s room. An interview was conducted with Employee # 3 on 07/23/24 at 8:57 a.m. Employee remembers taking care of Patient #1 on two different shifts. Employee #3 stated, “Eye drops were used for lubrication because the Patient wasn’t making tears or lubrication on their own. The Patient was turned every two hours, not always documented, normal protocol for every Patient is that Patients have to be turn every two (2) hours, looked at heels, hips, put ChapStick, mouth care, pillows under arms.” Employee #3 stated, “They did provide oral care with water and swap every two hours.” It was stated that “no documentation was captured.” Employee #3 stated, “They need two people to make the turns on the patient, it’s easier and safer. I never saw any sores on Patient #1 lower extremities.” When asked if the Patient’s room had hot water, Employee #3 stated, “[Patient #1] room did have water, not sure about hot water. Every staff member knows how to report an issue to maintenance.” An interview was conducted with Employee #4 on 07/23/2024 at 9:20 a.m. Employee #4 receives incident reports and enters them into the system. The director looks at the incident to see if they must correct an issue and makes that determination. Employee #4 enters the incident into the system, keeping it open or closed depending on the circumstance. Sometimes it takes one day or two days to take care of or resolve an incident. Employee #4 remembers the verbal incident when it was reported, and it was reported as resolved. Employee #4 stated, “There was no complaint or grievance filed by the spouse, if there had been I would have received it and followed the process.” An interview was conducted with Employee #5 on 07/23/24 at 10:55 a.m. Regarding Patient #1, Employee #5 stated, “I remember talking to spouse of Patient #1”, and Employee #5 stated, “The spouse was upset because Patient #1 had crusty eyes, at that moment Patient Care Technician (PCT) were giving a bath to the Patient #1. Patient relations staff ask if they could help the spouse if they wanted to file a complaint. I did not document the conversation between the Patient spouse and Patient relation staff. The spouse did not want to file a formal complaint, only wanted the patient to be bathed and to get a new bed. I went to talk to the unit secretary to order a new bed, but [he/she] was not sure if [Patient #1] bed was broken. The spouse’s concerns were addressed, and the spouse was fine.” Employee #5 doesn’t remember hearing any complaints about water issues or if any staff filed a maintenance order. Employee #5 stated, “It was reported to them that Patient #1’s spouse was visiting and that was their first time since the Patient was admitted.” An interview was conducted with Employee #6 on 07/23/24 at 11:36 a.m. Regarding Patient #1, Employee #6 stated, “I spoke with spouse one (1) time only. When I arrived at the Unit, the spouse said that they don’t need to talk because the staff is already taking care of [Patient #1], the spouse declined to file a formal complaint. Myself and [Employee # 4] went to verify if [Patient #1] was clean, and there were no issues after that.” A telephone interview was conducted with Employee # 7 on 07/23/24 at 12:47 a.m. Employee #7 states, “I don’t recall [Patient #1].” An interview was conducted with Employee #8 on 07/23/24 at 12:58 p.m. Employee #8 states, “The spouse is always calling and wants to talk to Patient #1.” Employee #8 states, “One (1) day the spouse showed up at the unit and spoke with me. We discuss [Patient #1] not being able to communicate and [Patient #1’s] health conditions. It was stated that the spouse was only there one (1) time, I think it was on 6/24/24. I did call the Ombudsman out of concern for the Patient.” Employee #8 stated, “[Patient #1] came from a local nursing home and after being there for a few days. They remarked that they can’t take the Patient back because they can’t take care of the Patient due to the severity of the medical conditions. The Ombudsman was notified regarding the concerns.” Employee #8 states, “The spouse was trying to find a place in the state of Pennsylvania because they have a better facility for [Patient #1] medical condition. [Patient #1 spouse] was willing to move when a facility like [another facility] in Pittsburgh admitted Patient #1. I sent referrals to find a place for [Patient #1], also remember a visit [Patient #1] but I didn’t see anything out of place.” An interview was conducted with Emp #9 on 07/23/24 at 2:03p.m., regarding patient #1. Emp #9 stated “I saw [Patient #1] the day after admission. [He/She] didn’t have any wounds on them. The bottom looked good. I ordered an air mattress the following day, and the wound care department saw [Patient #1] a total of three (3) times for assessments and recommendations. The consultation comes in, the staff looks at the report, primary care physician signs and the nurse does the initial assessment. When the nurse does the admission the provider notes are also there. When wound care receives the consultation, they must see the patient within twenty (24) hours. This consultation was to prevent wounds because [Patient #1] was not mobile. When we see the patients on the floors, we go in and check if they need a pillow, mattress or anything else we can do for them. We do the assessments and give recommendations to the nursing staff. The nursing staff and PCT’s carry out the recommendations through personal care tasks.” A telephone interview was conducted with Emp #10 on 07/23/24 at 2:30 p.m. Emp #10 stated, “When they perform trach care they do the mixing of solutions, and they perform trach care three (3) times a day. We suction as needed.” Emp #10 stated, “We don’t do mouth care. I don’t remember seeing the [Patient #1] with eye crust or with hygiene issues.” Emp #10 stated, “When you see something wrong with Patients it must be reported to the charge nurse. I saw [Patient #1] three (3) times a day and it’s documented, so if observations were made it had to be reported and in this case there was nothing to report.” An interview was conducted with Employee #11 on 07/24/24 at 8:45 a.m. Employee #11. Employee #11 stated, “When I arrived at the unit they received a paper with daily activities. I take the patient’s vitals and sugar levels. After the job is done, I have to chart on the Patient’s chart.” Employee #11 remembers taking care of patient #1 twice. “We take vitals, sugar, and check if [Patient #1] is wet.” Employee #11 stated, “I bathed Patient #1 both days. The first time was at the end of May, and I do not remember seeing any sores. The second time was around the end of June no sores either. [Patient #1] stated that spouse pointed to a place on the ankle that had dry skin but not sores, no scars, nothing. [Patient #1] has a special bed mattress; it inflates and deflates to relieve pressure and shift the patient. They also had special boots to relieve pressure and those were on. I spoke with the spouse who was upset due to patient health conditions, dirty, crusty eyes due to eye medication, upset about everything including the spouse’s living situations, and the spouse was there around lunch time. [Patient #1] was on the schedule to get a bath and I believe it was documented after the bath. When I was done bathing [Patient #1] the spouse was very happy. The chart nurse talked to spouse about the issues. Spouse was there for around five (5) hours. I left the shift and the spouse stayed there.” Employee #11 said, “The water in [Patient #1] room was taking a long time to get warm. An interview was conducted with Employee #12 on 07/24/24 at 9:07 a.m. Employee #12 remembers taking care of patient #1 maybe a couple times, doesn’t remember seeing any sores on Patient #1. Employee #12 stated that they did not use water in the patient’s room. “We typically use the bag bath so I couldn’t speak on the water situation. The bag bath allows us to bath the patient but control water in the bed, things getting wet.” Employee #12 believes that [Patient #1] had eye treatment due to an infection, doesn’t ever remember seeing crust in the patient’s eyes. Employee #12 stated, “Not every care task is documented, but should be though.” A telephone interview was conducted with Employee # 13 on 07/24/24 at 11:34 a.m. Employee #13 stated, “I do remember [Patient #1] and never reported or observed any bedsores.” Employee #13 saw [Patient #1] every day, “Patient was never dirty, no issues with their personal hygiene.” Employee #13 stated that anytime there was a change in Patients’ condition, the nursing staff would update and notify them of any issues. Employee #13 stated that the wound care order and recommendations is protocol for prevention only. “Its normal protocol when a patient is immobile, to look at skin condition and makes recommendation for skin care and prevent breakdown.” Employee #13 states that they have a team of doctors, and we see patients every day, we take care of the patients. Observations: An observation was made at the facility’s 8 East Unit on 07/22/24 at 2:50 p.m. The Unit is located on the 8th floor of the hospital. The floor is divided into two (2) units, East and West, Patient #1 was on East, room 836 at the time of the observation room 836 due to a Covid Patient could not be observed (statement made by Employee #2). The Unit has forty-eight (48) rooms, of which ten (10) rooms are single, and 38 rooms are double. At the time of the observation all the beds were occupied, staffing seven (7) Registered Nurses (RN), no License Practical Nurse (LPN), Two (2) Unit secretaries, and five (5) Patient Care Technician (PCT). Observed room 866 housekeeping, 865 clean utility room, 864 soiled utility it looks clean and organizes nothing out of place. Observed Med Room small with containers with medication, each Patient has their own containers marked with room number and Patient’s name. Observed a social worker and nursing room locked. Observed the refrigerator small, with a temperature log. Observed crash curt with log and locked. Also observed nurses’ station with nurses working on computers. An observation was conducted of 8 East on 7/23/24 at 1:40 p.m. Surveyor requested that Employee#14 perform a test by running the hot water in sink and filling a cup. The staff ran the water and the water in the cup was lukewarm. The staff stated that the water was draining very slowly so they couldn’t let the water run very long. A second test of the same room (836) produced slightly warmer results, but the drain was not draining appropriately. A third test was done in the room next door (838) and the water was warm, but the staff stated that “they couldn’t let the water run to get warmer because the sink was backed up and would overflow.” Policy A review was conducted of “Admission History & Assessment,” revised 4/24. The policy states in part, “Purpose: To accurately transcribe baseline data, assessment, and history of adult patient at time of admission. (2). To assure the timely and accurate determination of the patient’s individualized documentation of the nursing care process ... Procedure: Completed Integumentary Assessment, Complete Braden Scale Assessment, Institute appropriate interventions based upon Braden Scale score. Braden Scale documentation is required on admission and with every shift assessment. A review of the level eight (8) “Stop Pressure Ulcers Booklet,” states the following: “Skin assessment at admission and at least every shift. Turn and position at least every two (2) hours ... Accurate nursing documentation significantly influences the quality of patient care. It not only provides a clear picture of the patient’s medical history but also serves as a vital tool of communication among healthcare professionals. When filled accurately and systematically, it can also protect nurses legally if there’s a complaint or lawsuit related to patient care.” A review of the “Patient Care Manual: Turn Team-Skin Patrol,” revised 11/21. The policy emphasizes the procedure. “Procedure ... Documentation of care provided will be entered in the patient medical record.” A review was conducted of “SPECIALITY MATTRESSES/BEDS.” The policy states, in part, “Specialty Mattresses are used to prevent/treat skin breakdown in susceptible patients. All patients presenting with pressure injuries or a Braden Scale of 18 or below are recommended to use a specialty mattress.” A review was conducted of “SUSPECTED ELDER ABUSE OR NEGLECT,” initial date 03/2021. The policy states, in part, “... Policy: When caring for adult patients receiving services at Weirton Medical Center, all healthcare providers will be alert for signs and symptoms of abuse/neglect and refer to the appropriate provider for an assessment ... Purpose: The purpose of the policy is to identify adults suspected to be suffering from abuse and/or neglect, upon entry into the system and on an ongoing basis ...” A review was conducted of “ROUNDING POLICY (Rounding with a purpose),” last revised 11/2021. The policy states, in part, “... Policy: Hourly rounding, (rounding with a purpose), will occur on all patients in the following areas: Level 8, Level 7, Skilled Care, CCU, IMC, OB/Pediatrics and Emergency Department (ED). Houring rounding will focus on pain, position, toileting, personal needs and the patient room environment. The environment assessment will ensure personal items are in reach and safety measures are in place ... PURPOSE: The purpose of rounding with a purpose is to improve patient care by anticipating patient needs, improving pain management, reducing patient falls and skin breakdown, and improving patient safety through the use of evidence-based practice. The RN will be responsible for ensuring that rounding has occurred as scheduled and will delegate to the members of the Healthcare Team is appropriate.””

“FACILITIES CFR(s): 482.41(c) (d) Standard: Facilities. The hospital must maintain adequate facilities for its services. This Standard is not met as evidenced by: 43434 Based on documentation, observation and staff interviews, the facility failed to provide adequate water temperatures and appropriate drainage access to the patient. This failure has the potential to affect all patients within the hospital. Findings: A medical record review was conducted for Patient #1. Patient#1 presented to Emergency Department (ED) via Emergency Medical Services (EMS) from a local nursing facility. It was reported that the Patient was having episodes of breakthrough seizures. The Patient has a history of seizures and anoxic brain injury. The patient has also suffered two (2) cardiac arrests and has a surgical procedure (S/P) tracheostomy. Upon arriving at the facility, the Patient was oxygenating appropriately as evidenced by blood gases results. Chest x-rays were negative for any signs of pneumonia. Patient #1 was given a gram of Keppre in the ED. Urinalysis testing was indicative of urinary tract infection (UTI) and given Rocephin. Patient #1 is nonverbal and is diagnosed with Congestive Heart Failure (CHF), Edema, Hypertension, Myocardial Infraction and Urinary tract infection. Patient #1 was Admit on 5/28/24 at 7:26 p.m., for further evaluation. The Patient received a consultation to neurology on 5/29/24, for breakthrough seizures, and possible medication adjustment. CT scan was completed on 6/18/24, and reflected no intracranial hemorrhage, mass effect, or evidence of large acute infraction. The Patient received the following medical services: Arterial Blood Gas Test (ABG), Blood Grouping, Antibody screen, Basic Metabolic Panel (BMP), Comprehensive Metabolic Panel (CMP), Glucose Tolerance Test, Lactic Acid Test, Methemoglobin Blood Test, Computerized Tomography (CT), abdomen, pelvis and brain, Abdomen and chest x-ray, Respiratory Therapy, Wound Care, Esophagogastroduodenoscopy (EGD), Occupational evaluation and Physical Therapy evaluation. An order for Wound care was started on 5/29/24. The order was for wound care every week, foam, change dressing PRN, apply convafoam dressing to bilat heels, 7 days and prn. The medical record supported that the patient did not have pressure ulcers or any breakdown of the skin. Wound care was provided as a preventative measure due to the patient being bed fast and immobile. Wound care unit assessment notes completed by (Emp #9) and (Emp #13) for the days of 5/28/24, 6/13/24 and 6/20/24, reflect that Patient #1 had no skin breakdown, bottom was good. Preventive recommendations for foam for the bottom and heel boot for patient, change dressing as needed and apply barrier cream was documented. An interview was conducted on 7/23/24 at 8:30 a.m. with Employee #1. Employee #1 stated, “They were unaware of any issues with water not being hot or drainage issues in room 836.” Employee #1 referred to the maintenance orders for the time frame of 5/28/24 to 6/24/24 and found no orders for room 836. Employee #1 stated, “If there had been an issue with the water in the room, the staff would have put in a work order.” Employee #1 stated, “At no time did they hear of any water or drainage issue with the room, nor were they informed of a complaint.” Employee #1 stated, “I do routine water checks and produced a daily log of the boiler room showing where the actual checks were done. If there had been a problem with the water or drainage, or no water, that is a Patient care issue, and the Patient would have been moved out of the room. Drainage is a big issue, because it could smell or be a bacteria issue, the Patient would have definitely been moved from the room. Maintenance is available 24/7. I checked that room this morning before I came in here. There weren’t any issues with the water.” An interview was conducted with Employee #2 on 07/22/24 at 1:05 p.m. Employee #2 doesn’t remember any issues related to water in the Patient’s room. An interview was conducted with Employee # 3 on 07/23/24 at 8:57 a.m. When asked if the Patient’s room had hot water, Employee #3 stated, “[Patient #1] room did have water, not sure about hot water. Every staff member knows how to report an issue to maintenance.” An interview was conducted with Employee #11 on 07/24/24 at 8:45 a.m. Employee #11 said, “The water in patient #1 room was taking a long time to get warm.” Observations: An observation was made at the facility’s 8 East Unit on 07/22/24 at 2:50 p.m. The Unit is located on the 8th floor of the hospital. The floor is divided into two (2) units, East and West, Patient #1 was on East, room 836 at the time of the observation room 836 due to a Covid Patient could not be observed (statement made by Employee #2). The Unit has forty-eight (48) rooms, of which ten (10) rooms are single, and 38 rooms are double. At the time of the observation all the beds were occupied, staffing seven (7) Registered Nurses (RN), no License Practical Nurse (LPN), Two (2) Unit secretaries, and five (5) Patient Care Technician (PCT). Observed room 866 housekeeping, 865 clean utility room, 864 soiled utility it looks clean and organizes nothing out of place. Observed Med Room small with containers with medication, each Patient has their own containers marked with room number and Patient’s name. Observed a social worker and nursing room locked. Observed the refrigerator small, with a temperature log. Observed crash curt with log and locked. Also observed nurses’ station with nurses working on computers. An observation was conducted of 8 East on 7/23/24 at 1:40 p.m. Surveyor requested that Employee#14 perform a test by running the hot water in sink and filling a cup. The staff ran the water and the water in the cup was lukewarm. The staff stated that the water was draining very slowly so they couldn’t let the water run very long. A second test of the same room (836) produced slightly warmer results, but the drain was not draining appropriately. A third test was done in the room next door (838) and the water was warm, but the staff stated that “they couldn’t let the water run to get warmer because the sink was backed up and would overflow.” Return to observe Eight East on 07/23/24 at 3:20 p.m. Maintenance workers were in room 836 working on the sink drainage. Also, maintenance people were checking water temperatures in room 838 which water temperature was taken at 2:42 p.m. 108.3F. Policy: A review of the “WATER SYSTEM PROTECTION PLAN,” dated 2022 and managed by CHEMWAY was completed. Guidelines indicate the following: Weirton Medical Center WATER SYSYTEM PROTECTION PLAN, which will follow ASHRAE 188 and include; Identification of water safety team and responsibilities, water systems legionella hazard awareness, identification of control limits and operating goals, monitor sampling/testing schedule and procedures, corrective actions and documentation requirements ... Hot water outlets:8th floor general sink. A review was conducted of requested “Boiler Room” daily documentation. This surveyor was provided with only the current week of documentation. The documentation provided did reflect testing of the water system for a twelve (12) hour period each day. There were no issues noted on the testing records. No documentation was provided for the time period of 5/28/24 and 6/24/24. A review of a “CHEMWAY, TECHNICAL SERVICE REPORT” dated 6/5/24 was completed. Although the report measures a variety of indicators: condensate, feedwater, softener, boiler #1 and the cooling tower; there was no issues noted within the report. It was determined by the above findings that the facility was not in compliance with 42 CFR, Part 482.13 - Part 482.43 of the Medicare Conditions of Participation for Hospitals.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 40269 Based on document review and staff interview, it was determined the facility failed to follow their procedure for staffing by not following their staffing matrix. This failure has the potential to impact all patient care at the facility. Findings include: A policy was reviewed, titled “Nursing Services Policy”, last revised 12/19. The policy states, in part: “Policy: A sufficient number of qualified registered nurses and other nursing staff are on duty at all times to meet the patient’s needs, to be responsive to our patients and their families and to promote efficient operation of the hospital. Through the budget process, sufficient resources are allocated to continuously improve the quality of Nursing Care delivered ... Procedure: 1. Staffing patterns are established by the unit director for each department utilizing historical data, volume, and Acuity information with approval by the chief nursing officer. 2. These patterns are reviewed annually or more frequently if necessary, considering the following: patient outcome data, patient satisfaction data, severity, complexity and intensity of the expected patient population, skill set and expertise of staff, ancillary Services available, review of West Virginia code and guideline documents from the State Board of nurse examiners, guidelines and evidence-based standards from professional nursing organizations, external and Regulatory standards, nursing staff and medical staff feedback ...” The “Staffing Table Level 8 [eight]” was reviewed. The staffing table lists how many staff members should be present for the number of patients. The table starts at eighteen (18) patients through forty-eight (48) patients. For example, for forty-five (45) patients on “Days (7:00 a.m. though 3:00 p.m.)”, the staffing numbers show: “MGR-1, CS-1, CHG-2, RN-8, PCT-5, WC-2.5 [Manager-One, Clinical Supervisor-One, Charge Nurse-Two, Registered Nurse-Eight, Patient Care Technician-Five, Ward Clerk-Two point five].” For “Evenings (3:00 p.m. through 11:00 p.m.)”, the staffing numbers show: “CHG-2, RN-8, PCT-5, WC-2.5. For “Nights (7:00 p.m. through 7:00 a.m.)”, the staffing numbers show: “CHG-2, RN-8, PCT-4.” For forty-one (41) patients on “Days (7:00 a.m. though 3:00 p.m.)”, the staffing numbers show: “MGR-1, CS-1, CHG-2, RN-7, PCT-5, WC-2.5.” For “Evenings (3:00 p.m. through 11:00 p.m.)”, the staffing numbers show: “CHG-2, RN-7, PCT-5, WC-2.5.” For “Nights (7:00 p.m. through 7:00 a.m.)”, the staffing numbers show: “CHG-2, RN-7, PCT-4.” For thirty-seven (37) patients on “Days (7:00 a.m. though 3:00 p.m.)”, the staffing numbers show: “MGR-1, CS-1, CHG-2, RN-7, PCT-5, WC-2.5.” For “Evenings (3:00 p.m. through 11:00 p.m.)”, the staffing numbers show: “CHG-2, RN-7, PCT-5, WC-2.5.” For “Nights (7:00 p.m. through 7:00 a.m.)”, the staffing numbers show: “CHG-2, RN-7, PCT-3.” Staffing was reviewed for the past six (6) months on Unit 8. On 07/12/23 for 7:00 p.m. through 11:00 p.m., the patient census was forty-one (41) with five (5) RNs, one (1) Charge RN, one (1) Ward Clerk and two (2) PCTs. On 07/12/23 for 11:00 p.m. through 7:00 a.m. shift, the patient census was forty-five (45) with five (5) RNs, one (1) Charge RN, and two (2) PCTs. On 11/02/23 at 3:00 p.m. through 7:00 p.m., the patient census was thirty-seven (37) with seven (7) RNs, one (1) Charge Nurse, three (3) PCTs and one (1) Ward Clerk. On 11/02/23 at 7:00 p.m. through 11:00 p.m., the patient census was forty-one (41) with seven (7) RNS, two (2) Charge Nurses, and three (3) PCTs. Several shifts and days were observed to not be staffed according to the staffing matrix. An interview was conducted with employee (emp) #4 on 11/13/23 at 4:00 p.m. Regarding staffing, RN #4 states, in part, “We have not been fully staffed with techs for a long time. Unit 8 actually has the most techs. If we know that we’re going to be short-staffed, first, we call the float pool staff, then we call the administrator on call to see if we can offer critical pay. The Charge Nurse on the floors can call their own staff. We have had holds in the ED if there’s not enough staff on the floor. We usually work it out. We don’t like staff to go above nine (9) patients a piece at night, and the Charge Nurse can always take a couple patients. It’s a normal thing for all staff to complain about staffing but if we don’t have any to give, they seem to make it work.” An interview was conducted with emp #8 on 11/14/23 at 8:52 a.m. Regarding staffing, emp #8 states, in part, “We make routine calls first to ask if anybody will pick up an extra shift. We see if the float pool is available, then we see if staff can be available from another floor. If still no one, then critical pay is given to any staff that pick up ... Our staffing Matrix was made long before I started, years ago. No one has reviewed or revised the Staffing Matrix in a long time, but we still use it.” An interview was conducted with emp #10 on 11/14/23 at 11:27 a.m. Regarding the staffing matrix, emp #10 states, “I am unsure why this is being used; this is a very old matrix. I’m going to go look to see if there’s an updated Matrix available.” On 11/14/23 at 12:15 p.m., emp #10 confirmed the staffing matrix presented was the one currently in use, and it had not been updated.”