Man Held At Sharpe Hospital Sues State Officials

A patient at Sharpe Hospital has filed a lawsuit against the facility, its CEO and state health officials.

Editor’s note: The following may be disturbing for some readers.

Disability Rights West Virginia (DRWV) has filed a lawsuit on behalf of an adult male, referred to as J.P., with developmental disabilities that says he has been physically abused and wrongfully held at William R. Sharpe Hospital for more than 570 days.

DRWV is the state’s federally-mandated protection advocacy system for people with disabilities.

On Sept. 14, 2022, J.P. was removed from a Westbrook facility and sent to Sharpe Hospital. 

Westbrook is a company that runs residential housing for people with disabilities. Sharpe Hospital is a psychiatric facility under state operation. 

According to the Office of Health Facility Licensure and Certification (OHFLAC), Westbrook’s care provider and licensed social worker falsely represented to the Wood County mental hygiene commissioner that J.P. “violently and aggressively attacked his roommate” to attempt to justify J.P.’s improper involuntary civil commitment. 

Tina Wiseman, the OHFLAC director who oversaw the investigation of the incident stated, according to the lawsuit, the incident did not occur. 

“We did an investigation when I was at OHFLAC and what the provider wrote down on the commitment papers didn’t take place,” Wiseman said. “We watched it on the video, and it did not take place. There needs to be something that holds that provider accountable when they falsify commitment papers to get the person out of there. I mean they’re stripping someone of their rights there’s just no accountability…You never ever would have known, I mean they said he [J.P.] viciously attacked his roommate. He never touched him. He never touched him. It was pretty horrible.”

Legal Director for Disability Rights West Virginia, Mike Folio said J.P. is being held unlawfully at Sharpe Hospital.

“J.P.’s case is absolutely egregious because he was in a community setting, and evidence provided by the former OHFLAC director is that Westbrook, a community-based provider that was responsible for caring for J.P. falsified the application to get him involuntarily committed,” Folio said.

A month after arriving at the facility, on Oct.  12, 2022, Sharpe Hospital determined that J.P. was “eligible for discharge and clinically stable.”

The hospital determined that his purported behaviors were related to his developmental disability and “not any psychosis,” as is required by West Virginia state code for involuntary commitment to a state hospital.

“A diagnosis of dementia, epilepsy, or intellectual or developmental disability alone may not be a basis for involuntary commitment to a state hospital,” state code states.

On or before Oct. 12, 2022, Sharpe Hospital reported that Westbrook refused to accept J.P. if he were to be discharged. The hospital also documented that Westbrook’s strict criteria are unrealistic and attainable for J.P. and questioned the original mental hygiene petition, or referral to Sharpe, since the hospital has not observed the behavior reported in the petition.

On Oct. 19, 2022, five days after Sharpe Hospital’s finding that J.P. was clinically stable and ready for discharge, the Lewis County Mental Hygiene Commissioner, Brian W. Bailey held a hearing and entered an order that civilly-committed J.P. to Sharpe Hospital.

According to the lawsuit, Sharpe Hospital clinicians have shared that J.P and other persons in similar situations are “decompensating” during their commitment to the hospital given the chaotic psychiatric hospital environment.

“J.P. is really, sadly, he’s the poster child for a failed system where the Department of Human Services that’s responsible for overseeing and providing community placements isn’t doing it, then it’s a failure of the Secretary of the Health Facilities to continue to keep somebody locked up,” Folio said.

Sharpe CEO Patrick Ryan, Department of Human Services Secretary Cynthia Persily and Department of Health Facility Secretary Michael Caruso were also named as defendants.

“We’re naming all of the responsible parties, including the Chief Medical Officer who has the ability to discharge him, the Administrator of Sharpe Hospital who continues to allow him to be unlawfully committed, the Secretary of the Department of Health Facilities that has the authority to discharge him or direct the discharge, but he won’t,” Folio said. “And then Secretary (Cynthia) Persily, who’s the Secretary of the Department of Human Services that oversees the community placements. So all of these individuals collectively and individually, have really combined to create this pattern of J.P. being unlawfully committed and continuing to be unlawfully committed.”

On Jan. 30, 2023, Westbrook notified J.P.’s mother and guardian that Westbrook had discharged J.P. and he was prohibited from returning to his prior residence. In addition, Westbrook stopped providing IDD Waiver services to J.P. and charged him rent for a Westbrook residence from the time of his involuntary civil commitment until his discharge from Westbrook’s service even though he was not living there.

J.P.’s Sharpe Hospital records reveal that J.P.’s behaviors escalate over his frustration with remaining at Sharpe Hospital and he repeats, “Go home, go home.”

On or about June 9, 2023 one or more Sharpe Hospital employees abused and physically assaulted J.P., according to an investigation by Legal Aid of West Virginia (LAWV), cited in the lawsuit.

LAWV obtained a statement from Dr. Abid Rizvi, J.P.’s primary treating psychiatrist, and Dr. Rizvi observed that J.P. was physically abused.

In an interview with LAWV, Rizvi said the bruising could not have been self-inflicted and that a bruise on J.P.’s back resembled a shoe print.

“So you have a staff member who physically battered a vulnerable protected person,” Folio said. “And again J.P.’s own physician has said this, not us J.P.’s own physician or psychiatrist and the person who battered him walks around with impunity that consequences are nothing.”

Ryan and Caruso have stated that J.P. was not abused or assaulted.

A spokesperson for the Department of Health Facilities and Department of Human Service’s Office of Shared Administration told West Virginia Public Broadcasting:

“The West Virginia Department of Health Facilities and Department of Human Services are in receipt of the complaint and are reviewing it with litigation counsel at this time.”

A patient advocate took photos of J.P. inside Sharpe Hospital following the alleged abuse.

Courtesy Photos

Big 3 Drug Companies Argue For Supreme Court To Block Possible Appeal

Depending on what the court decides, it could allow the localities to appeal an opioid case they lost two years ago.

The City of Huntington and Cabell County have asked the West Virginia Supreme Court of Appeals to define what constitutes a public nuisance under state law. 

Depending on what the court decides, it could allow the localities to appeal a case they lost two years ago. 

The defendants – Amerisource, Cardinal Health and McKesson – have filed a brief that argues that the high court should uphold the previous narrow interpretation by the circuit court of what is considered a public nuisance. 

“If this court chooses to answer the certified question, it should confirm that West Virginia public nuisance law does not and should not apply to the distribution of lawful products like prescription opioid medications,” the brief said. 

The plaintiffs said that the court has never applied public nuisance law to the distribution of products. They said that the localities failed to provide any state example in which a public nuisance had been applied to the distribution of products. 

The brief goes on to outline that localities have exaggerated and distorted the companies’ role in the epidemic. While the companies acknowledge there is an opioid epidemic, they say in the brief that they didn’t cause it. 

“(Distributors’) conduct in shipping prescription opioids, needed to fill legitimate prescriptions written by West Virginia doctors, was not wrongful and did not cause the opioid epidemic,” the brief said. 

The defendants also took issue with the plaintiffs suing for a large sum of money as a form of abatement. 

“Even where parties have been ordered to clean up environmental nuisances, the remedy never included paying for the treatment of downstream personal injuries or social programs with remote connections to the defendant’s conduct,” the brief said. 

The State of West Virginia’s case, also based on the idea that opioids created a public nuisance, yielded a billion-dollar settlement. However, it was settled outside of court. 

If the court rules that the distribution of opioids constitutes a public nuisance, then Huntington and Cabell can request an appeal. 

The localities will still have to prove in an appeals case that the distributors caused harm, that the distributors’ conduct was unreasonable, and that they have requested proper abatement to remedy the damage. 

The court is expected to decide by the end of this year. 

A Winding Search For Accountability In The Starving Death Of Boone County Child

The advocacy organization representing those with disabilities in West Virginia has filed a notice of suit against Gov. Jim Justice, other top state officials and agencies.

Disability Rights West Virginia filed a notice of legal action Thursday against Gov. Jim Justice, Secretary of the Department of Human Services (DoHS) Cynthia Persily, Attorney General Patrick Morrisey and the West Virginia Department of Human Services itself.

The letter was sent to each party and members of the media, alleging the DoHS violated its Child Protective Services Policy and the Child Abuse Prevention and Treatment Act (CAPTA) in connection with the death of a child in Boone County, W.Va.

History Of The Case

On April 17, Julie Anne Stone Miller was arrested and charged with child neglect causing death after her daughter was found “emaciated to a skeletal state,” the Boone County Sheriff’s Office told Eyewitness News. She has pleaded not guilty to the charge.

Deputies responded to a death call in Morrisvale, Boone County that morning and found the girl, later identified as 14-year-old Kyneddi Miller, on the bathroom floor on a foam pad.

According to the complaint, she had an eating disorder for several years. The child’s grandmother was interviewed as part of the investigation and told deputies the girl had not attended school or left the house, except possibly two times, in the last four years.

The grandmother also said the child had not been eating for months, and was unable to function on her own for four to five days prior to her death due to her physical state.

On May 20, Kyneddi’s grandparents, Donna and Jerry Stone, who shared the home with Kyneddi and her mother, were arrested and charged with child neglect causing death.

Was CPS Involved Or Not? A Timeline Of Seeking Accountability.

After the news of Kyneddi’s death broke, media outlets across the state began asking questions of state officials.

DoHS Cabinet Secretary Cynthia Persily released a statement April 22. The press release provided no further information on the case, but cited West Virginia Code that all records and information concerning a child or juvenile that are maintained by DoHS are confidential and may not be released or disclosed to anyone, including any federal or state agency.

The release further cited CAPTA, one of the laws Disability Rights West Virginia now accuses the department of violating, as requiring it to preserve the confidentiality of all child abuse and neglect reports.

“The role of DoHS’s CPS is to investigate allegations of abuse and neglect when the allegations are against a parent, guardian or custodian,” the release reads. “Child safety is paramount in all CPS investigations. CPS policy and Chapter 49 of the West Virginia Code require that any report alleging abuse or neglect of children is to be investigated/assessed by DoHS.”

The statement by Kyneddi’s grandmother, Donna Stone, saying she hadn’t been in school since 2019 prompted the media to ask Justice during his weekly media briefing on April 23 if the girl had been homeschooled and if so, why an academic assessment hadn’t brought attention to her condition.

“I think the answer just got to be just one thing,” Justice said. “The CPS folks, from what I understand, [had] no idea about this, about this child, no idea whatsoever.”

On April 26, Eyewitness News reported that they had received documents through the Freedom of Information Act (FOIA) confirming Kyneddi started homeschooling in February 2021 at the request of her mother, citing concerns about the COVID-19 pandemic.

Television station WSAZ published evidence from their own investigation and a whistleblower on May 6 as part of their investigation into the incident, Deadly Details Denied

Reporter Curtis Johnson was denied documents by the Department of Human Services and referred back to the statement. In the law on confidentiality, he found that the department, in case of a child neglect fatality, “shall make public information relating to the case.” Johnson found that same requirement in federal law.

Johnson submitted a FOIA request for any history that CPS had with the Boone County teenager. His request was denied.

Johnson later set up an interview with Persily where he repeatedly asked her if the DHS had any knowledge of Kynneddi.

“We have no record of contact with this family — about this particular child,” Persily told Johnson.

After speaking with Persily, the station received a response to their FOIA request sent to the West Virginia State Police. The response includes notes from a welfare check on the teenager in March 2023. The trooper who responded can be heard on audio files obtained by the station saying he is referring the child to CPS.

On May 8, Justice walked back his prior comments during a regular media briefing.

“Will I stand behind what I said two weeks ago now that I know the information I know today? No way,” Justice said in response to a question from Johnson.

Justice blamed the DoHS attorneys for the confusion.

“When they give us information, then we’ve got to act on the information they give us,” Justice said.

The Justice administration has said it is exploring ways to legally provide better information to the public. 

“I’ll absolutely direct them to follow the law. You know, without any question,” Justice said. 

Persily said that the administration is also looking to other states to understand their transparency practices. Persily advised journalists and members of the public to obtain and use the critical accident report that is filed annually. 

“That report, of course, has not been reported on in the media,” Persily said. “And we would just encourage everyone who wants to have information about child fatalities in the state to look at that report and the information is contained there.”

However, that report shows limited details on CPS actions, responsibility and culpability. The current report does not have any information of the death of Kyneddi Miller.

On May 21, Persily released a statement refuting the report from WSAZ.

“We are aware of information suggesting that West Virginia State Police intended to make a referral on this child in March 2023,” Department Secretary Cynthia Persily said. “However, a comprehensive search of DoHS records suggests no referral was ever made.” 

Nearly two weeks after WSAZ’s report, Persily reiterated the department had no records of abuse. 

“DoHS never received an abuse or neglect referral relating to the death of Kyneddi Miller, and was therefore not involved in the life of this child prior to her passing,” Persily said. 

In the same statement, Persily said that the whistleblower broke state and federal law by sharing the information with WSAZ. 

“We are extremely disappointed by the disclosure of information relating to those prior matters by an anonymous informant and by members of the local media,” Persily said.

Notice Of Suit

On May 23, Disability Rights West Virginia filed a notice of legal action against state officials and the DHS alleging the department concealed documents and information related to Kyneddi’s death.

The notice demands the named parties “cease and desist from any further violation of applicable law regarding the mandatory public disclosure of information and documents related to the Boone County death, child abuse cases, child abuse investigation and child abuse findings.”

The notice also requests documents and electronically stored information from DoHS leadership computers, phones and tablets be preserved. 

The advocacy group cited the federal Child Abuse Prevention and Treatment Act, which mandates that child abuse information be publicly disclosed.

The notice also asked that the agency “cease and desist from any threats, intimidation, termination or retaliatory actions against any person and any DHS worker who fulfills DHS’s mandatory duty of disclosing required documents and information.”

Tension Between Media And Executive Branch

In an incident recorded and published on May 22 by WSAZ, Justice’s Chief of Staff Brian Abraham could be heard yelling down a Capitol hallway, “Channel 3 is banned,” as reporters Johnson and Sarah Sager were working to learn more about Kyneddi’s case.

Abraham can be heard saying, “You’re not very good at your job.” He went on to say, “You are not doing a very good job at all.”

According to the reporters, this happened as Sager was waiting to interview state Sen. Eric Tarr, R-Putnam, and Speaker of the House Roger Hanshaw, R-Clay, about their closed-door meeting with the DoHS and members of the governor’s staff.

During a virtual press briefing on May 24, West Virginia Public Broadcasting asked Justice his response to the filing and accusations of retaliatory behavior.

“I don’t know, the allegation about, you know, threats or whatever, but I want to tell everybody that works in any capacity for me, and this government in any way, that I want you to always be 100 percent transparent on anything, and nobody, nobody’s gonna come back on you for anything, you know, if you’re just being that transparent and telling the truth,” Justice said.

Justice said if someone wants to file a lawsuit against him, they can.

“From the standpoint of the lawsuit against me, well, you know, people can do that if they choose,” Justice said. “But there’s no champion ever, is going to champion more transparency, and trying to do goodness, and help our kids and look after our kids than myself.”

Also during that press briefing, Eyewitness News’ Leslie Rubin and WSAZ’s Johnson said they’ve received multiple reports that the police officer who visited Kyneddi’s home drove straight to his local DoHS office, in person, to make the CPS report.

“There’s an officer that says that he drove, I guess his personal vehicle or whatever, he drove to the offices and went in and made that report,” Justice said. “At the same time, there’s no evidence that I can uncover so far that a report was made.”

Justice asked the public to remain vigilant and asked anyone with concerns about a child to call the Centralized Intake for Abuse and Neglect Hotline at 1-800-352-6513.

They’re Not Doctors. But They’re On The Front Lines Against W.Va.’s Health Struggles.

Lyle Marcum can’t drive to the doctor when he’s feeling ill. He couldn’t go to a downtown grocery store if there was one, which there isn’t. But when he has a hankering for fresh watermelon, he takes his wheelchair across the railroad tracks to where the Williamson Health and Wellness Center operates a farmers market.

Written by Laura Williamson, American Heart Association News

WILLIAMSON, West Virginia — Lyle Marcum can’t drive to the doctor when he’s feeling ill. He couldn’t go to a downtown grocery store if there was one, which there isn’t.

But when he has a hankering for fresh watermelon, he takes his wheelchair across the railroad tracks to where the Williamson Health and Wellness Center operates a farmers market.

As he shops for fresh fruits and vegetables, the 71-year-old stops to chat with the community health workers he credits with keeping him alive.

“If it wasn’t for them, I wouldn’t be here today,” he said.

Marcum lost his left leg to Type 2 diabetes and has been diagnosed with high blood pressure and heart disease. He’s one of thousands of residents who benefit from the center’s work tackling the devastatingly high burden of chronic illness in this small, rural Appalachian community in southwestern West Virginia.

At the center of it all are the community health workers, or CHWs, whose job includes helping clients learn to eat healthier and so much more.

The CHWs literally keep hearts beating in this coal-mining town along the Tug Fork River, overlooking the Kentucky border. Williamson is the seat of Mingo County, where the population has been steadily falling for years.

In a state ranked among the least healthy in the nation, where nearly 1 in 3 people describe their health as fair or poor, statistics suggest Mingo County’s roughly 22,000 residents face the biggest health challenges of all.

Their life expectancy is an estimated 67.2 years based on figures from 2019-2021, according to the latest County Health Rankings and Roadmaps data. That’s compared to 72.9 years for West Virginia and 77.6 for the nation during that same time period.

About 17% of adults in West Virginia have diabetes and 15% have cardiovascular disease – the highest rates in the nation, according to an America’s Health Rankings’ analysis of federal data that also showed 43% have high blood pressure. The county rankings show roughly 42% of Mingo County adults struggle with obesity, 37% are physically inactive and 28% smoke – all rates that exceed state and national averages. Poverty, lack of health insurance and scarcity of hospitals and health care professionals exacerbate these challenges.

Williamson residents also have high levels of food insecurity. So, community health workers distribute boxes of heart-healthy foods and show residents how to cook them.

Because the area lacks recreational facilities, CHWs organize walking groups and free community yoga classes. They also go to the homes of people like Marcum to take blood pressure and blood glucose readings and to help them manage their medications.

One of the most important roles the health workers play is to listen to their clients’ problems and encourage them when they feel frustrated and discouraged.

“They’re like family,” said Marcum, who told his care team, “I don’t need a wife. I got you all.”

“Some of these people have no family,” said Stephanie Bowman, a certified nurse practitioner and project manager for the CHW program in the department of family and community health at Marshall University’s Joan C. Edwards School of Medicine in Huntington, which provides ongoing training and technical assistance to their sites. “Just to have that visit even once a week, it makes all the difference in that person’s life.”

Williamson was the first of 24 sites serving 800 people across West Virginia, Kentucky and Ohio to use the CHW model developed under a 2012 federal grant.

The CHW model quickly proved successful. Within six to 12 months after enrollment, 60% of participants had lowered their A1C – a test that measures average blood glucose control for the past two to three months – by 2.4%. Emergency room visits fell 22% and hospitalizations declined 30% within a year.

When the grant ended in 2015, the model’s developers obtained funding to replicate it on a larger scale, while working with health insurers and Medicaid managed care organizations to create a shared payment plan that would sustain it on a longer-term basis.

Initially focused on helping people with high-risk diabetes, the model expanded in 2017 to cover other chronic illnesses, including heart disease and chronic obstructive pulmonary disease, and continues to expand.

CHWs are at the center of care teams managed by a nurse, nurse practitioner or doctor, who stays in contact with the primary care provider to make sure a care plan is being followed. CHWs are full-time employees and work directly with the patients, reporting back to the nurse. They are intentionally not medical professionals.

“The community health worker is a peer, a neighbor,” Bowman said. “They know the community and they understand the culture. They have the ability to see the person in their home, with the patient at ease, to be in a space where they can learn their self-management skills.”

When a patient enters the program, “we ask that they do a home visit right away,” Bowman said. Sometimes, a patient is reluctant to have someone in their home, so they meet at a neutral location, such as a library or a park. “But eventually that home visit happens, and that’s when the transformation begins.”

Once a CHW enters a home, they can identify the challenges the patient faces, Bowman said. They may not have enough resources to feed themselves, or they may be eating foods contributing to their illness. They may not be getting enough physical activity or know how to properly manage their medications.

“Sometimes it’s just a matter of needing better organization or understanding what resources are available when they have food insecurity,” she said.

Sometimes, the problem is keeping medical appointments.

“A lot of times, people don’t go to the doctor unless there’s something wrong with them,” said Samantha Runyon, one of Williamson’s community health workers. “And then they have transportation issues, insurance issues.”

Checking blood glucose and blood pressure levels regularly allows the team to better track people’s health so they don’t get sick, Runyon said. “If they have high blood sugar, we can speak to their doctor and get changes made to their medications sooner, rather than them waiting until their follow-up appointment to see the doctor.”

More often than not, a personal bond forms. And that’s when real progress begins, Bowman said. Community health workers “have the ability to connect and build rapport with the patients. When they do, magic just happens.”

Tony Delong can attest to that. His blood pressure and blood glucose levels were so high that when he first went to the wellness center for a checkup, he was immediately enrolled in the CHW program.

“They got me started that day,” he said, remembering how his A1C had climbed to more than 14% – double the goal for most people living with diabetes. After prescribing medication, CHWs “came to my home and called me every couple of days to do my readings – my weight, my blood pressure and check my blood sugar.”

The 64-year-old said the CHWs didn’t just manage his health. They also provided moral support and encouragement, getting him involved in support groups for people with diabetes and heart disease. They encouraged him to walk several miles a day and provided him with a blood pressure monitor so he could take readings on his own. Within a few months, his A1C was within goal and his blood pressure had returned to normal.

“They kept me motivated, and that includes helping me with things to eat,” Delong said. “I used to be a meat-and-potatoes guy. Now I’m practically a vegetarian.”

A big part of the job is helping people manage their risk factors to prevent progression of heart and kidney disease, said Melissa Justice, a nurse on one of the care teams.

Craig Warren has both. The 57-year-old entered the program a decade ago after he had a stroke, then had a toe amputated from nerve damage caused by Type 2 diabetes. The medication he took for his toe contributed to kidney damage, Justice said, and three years ago Warren received a kidney transplant.

Justice works with him to keep his blood glucose and blood pressure levels under control so that he doesn’t need to see his kidney doctor, 30 miles away in Logan, or his transplant team, 81 miles away in Charleston. His cardiologist is also 80 miles away, in Huntington.

“We have to keep up the preventive work so they don’t have to see a specialist,” said Justice, who coordinates the wellness center’s community health worker program. “We have no specialists here.”

Justice said the people they see have made steady progress, particularly in blood pressure control. In 2019, 65% of patients had blood pressure under control. In 2020 – the first year of the COVID-19 pandemic – that percentage rose to 72%, increasing to 75% in 2021. Currently, about 77% of patients maintain blood pressure within the normal range.

While enrollment in Williamson’s program was initially slow, it quickly picked up and at times, they’ve had more people seeking services than they could help.

“I’m one of the lucky ones,” Warren said. “I’m lucky to be alive.”

American Heart Association News sent reporters to five states to cover rural health challenges, and how people in rural America are working to overcome them.

Lawmakers Search For Answers In Elderly Patient’s Boiling Death

The commission that oversees West Virginia’s state-run hospitals questioned state officials but received few answers following the January death of a man held at a state-run psychiatric facility.

The Legislative Oversight Commission on Health and Human Resources Accountability (LOCHHRA) attempted to get more information Tuesday about the circumstances surrounding the death of an elderly, nonverbal man who was left unattended in scalding water at Hopemont Hospital, a long-term care facility in Preston County.

What Happened?

In January, an elderly, nonverbal man with dementia was left in scalding hot water by nurses at a state-run, long-term care facility. The man, referred to as Resident #19 in the Office of Health Facility Licensure and Certification’s (OHFLAC) report, had burns covering 35 percent of his body from being left in the 134 degree whirlpool bathtub for 47 minutes.

In a press release from Jan. 5, the West Virginia Department of Health Facilities (DHF) released a statement calling the incident an “equipment malfunction.”

“A thermostat on a water tank servicing one residential unit failed resulting in unsafe water temperatures,” the release reads. “Subsequently, one resident of the facility was treated for burns.”

According to the OHFLAC report, the nurses on staff did not tend to Resident #19’s burns immediately or call 911. They conferred with one another about whether or not the man had a skin condition that could cause his skin to peel before realizing he was burnt from the bath. 

Two hours after the incident began, the man was transferred to a local hospital, then to a burn unit in another state where he later died from his injuries.

State Lawmakers Want Answers

Lawmakers were met with little response from general counsel for the Office of the Inspector General, Jessica Whitmore, who told lawmakers she could not provide details about the case, only the procedure of the investigation.

“I cannot discuss specifics of this report,” Whitmore said. “This report was conducted pursuant to federal regulation, and federal regulation by the CMS (Centers for Medicare and Medicaid Services) does not allow us to testify about specifics of reports.”

Sen. Vince Deeds, R-Greenbrier, asked Whitmore what federal regulation prevented her from discussing the report. 

“There should be a mechanism for transparency and clarity within a facility,” Deeds said. “I just don’t feel quite comfortable with it right now. It feels like you’re trying to give me partial answers to things, because there may be some reasons that you just don’t want to discuss this.”

Whitmore cited federal regulation under 45CFR part two, which provides procedures when voluntary testimony is requested or when an employee is subpoenaed.

“It says we cannot discuss the specifics of any investigation we do pursuant to our agreement with CMS as the state survey agency,” Whitemore said.

Legal Director of Disability Rights of West Virginia Mike Folio told WVPB Wednesday the Office of the Inspector General (OIG) should have been able to answer LOCHHRA’s questions.

“For OIG to send an attorney up there and not to answer subsequent questions is just outrageous to me,” Folio said. “And I’m not necessarily faulting the attorney. I’m faulting the inspector general, who was the governor’s deputy chief of staff.”

In response to a question from Del. Amy Summers, R-Taylor, Secretary of the Department of Health Facilities Michael Caruso said he is not allowed to elaborate on the investigation.

“What I would like to expand to tell you is that when an isolated incident occurs, in any facility, we immediately jump on that situation, we’re the ones that reported to OHFLAC, we’re the ones that call all the other entities that then get involved in that process, we’re the ones that solve the problem, and we solve that problem pretty quickly, with an unfortunate situation that it did occur,” Caruso said.

A Timeline Of The Incident

*Editor’s note: The following may be difficult for some readers.

On Jan. 4, 2024, according to the OFLAC report, a nurse aide put the man, who was nonverbal, into a whirlpool tub and filled the tub to knee level, then realized the water was too warm and asked another aide to try to adjust the water.

“I walked in and put my hand in the water and said, ‘that’s hot.’ The [sic] looked at the temp gauge and it was 134 (degrees),” a nurse’s aid said in a statement in the report. “The water was past his knees but not running. I immediately turned the temp down and ran cold water in the bath. It cooled down and I went out of the bath back to my task I was doing. Then when I walked back up the hall, I overheard he had blisters and recalled what happened. I knew the bathtub would go to 140 (degrees) but I didn’t report it because the other staff told me it was normal and how to fix it.”

According to the report, readings of water temperatures taken from January to December 2023 show the water temperature at Hopemont Hospital was consistently above the regulation 110-degree maximum.

“This gentleman had no reason to die, none at all,” Folio said. “It’s quite appalling, quite frankly. I have evidence that for months before this gentleman was placed in a whirlpool to be boiled alive, that their maintenance team knew and their nursing staff knew that the water temperature at this location was around 134 degrees.”

Recent History Of Too Hot Water 

In December 2023, the month leading up to the incident, temperature readings were 126 degrees at its lowest on Dec. 21, 2023. The highest temperature recorded in December was 140 degrees and the water was that temperature on Dec. 6, 13, 14 and 22.

“The temperature, by regulation generally speaking, is supposed to be maintained by the facility,” Whitmore said. “If they are not in compliance with it, the facility would have the responsibility of coming into compliance. So that doesn’t always mean that they report it to us as a deficiency. It’s if you are running a facility and you see a problem, you are expected to fix it prior to us. There’s no mandated reporting.”

There were three Facility Reportable Incidents reported on Jan. 4 at Hopemont Hospital. The first was the report of the resident’s burns.

“Imagine being in water at that temperature for 47 minutes,” Folio said. “You’re elderly, you have dementia and you’re nonverbal. He couldn’t even scream for help, because he was nonverbal. They abandoned him while the staff members are out there in the hallway, surfing the internet on their phones.”

Needs Not Addressed Quickly

The second incident report stated that the registered nurse did not assess or treat the resident with severe burns timely. According to the report, the registered nurse (RN) was suspended in addition to the nurse aide.

According to the statement of one of the health service workers, the patient was left in the empty tub for a while after the incident before staff moved the patient to his room.

“I decided he needed to be moved to his room via wheelchair because he was ripping his skin off his legs by rubbing them together and ripping the skin off his feet by rubbing them on the drain,” the statement reads. “We put him to bed and placed wet rags on his burns and stayed with him trying to keep him comfortable waiting to see what was going to happen.”

Emergency Medical Service records referenced in the report show no one called 911 until 8:54 p.m. The resident was taken to the tub room at 7:12 p.m.

According to the Nursing Home Administrator’s statement, he went to the nurse’s station after watching the resident writhing in pain and advised the RN that the resident needed pain management immediately.

Regulatory Guidelines Not Met

A third facility-reported incident dated Jan. 4, 2024 stated the maintenance supervisor had been monitoring water temperatures for over six months, which did not meet regulatory guidelines. The Maintenance Supervisor failed to report the temperatures or attempt to make any changes to meet regulatory compliance. The report said he was aware of the guidelines for water temperature and chose to keep it warmer per staff request.

Hopemont Hospital was surveyed by a team from the Office of the Inspector General from Jan. 9, 2024 to Jan. 12, 2024 and had 44 residents.

On Jan. 11, 2024, Hopemont Hospital adopted a bathing policy which includes taking water temperatures prior to individual resident bathing to ensure a temperature of no higher than 110 degrees Fahrenheit, and supervision of residents during bathing to prevent harm.

A Painful Death

A report from the local hospital where the resident was transferred revealed the resident had third-degree burns to bilateral lower extremities and feet, left hand, bilateral buttocks and scrotum. The estimated surface area of the burns was 35 percent of his body.

The report concludes with the man being transferred to Preston Memorial Hospital for emergency care, then transported to a neighboring state burn center, but he succumbed to his injuries according to Disability Rights of West Virginia.

A spokesperson for the state health department told West Virginia Watch the department fired four nurses, including three contract employees, who were involved in the patient’s death.

Appalachia Health News is a project of West Virginia Public Broadcasting with support from Marshall Health.

Department Of Human Services Continues To Deny Culpability In Passing Of Boone County Girl

Cynthia Persily sat down with a WSAZ reporter to discuss the case. Persily told WSAZ that the Department of Human Services had no records at all of Kyneddi Miller.

The West Virginia Department of Human Services (DoHS) released a statement Tuesday refuting recent reports from southern West Virginia television station WSAZ about the 14-year-old girl who was found in a near skeletal state by Boone County deputies. 

The station recently reported that the Department of Human Services did in fact have contact with the family of the now deceased Kyneddi Miller. This was based on documents from an anonymous whistleblower who claimed to be a social worker with the department. It included cases in 2009 and 2017. 

Additionally, the station had information from the state police indicating that Child Protective Services had been notified about the alleged abuse and neglect. 

“We are aware of information suggesting that West Virginia State Police intended to make a referral on this child in March 2023,” Department Secretary Cynthia Persily said. “However, a comprehensive search of DoHS records suggests no referral was ever made.” 

Nearly two weeks after WSAZ’s report, Persily reiterated the department had no records of abuse. 

“DoHS never received an abuse or neglect referral relating to the death of Kyneddi Miller, and was therefore not involved in the life of this child prior to her passing,” Persily said. 

In the same statement, Persily said that the whistleblower broke state and federal law by sharing the information with WSAZ. 

“We are extremely disappointed by the disclosure of information relating to those prior matters by an anonymous informant and by members of the local media,” Persily said. 

Exit mobile version