By Erin Beck
A Sharpe Hospital employee allegedly strangled a patient who has a traumatic brain injury, according to a Lewis County criminal complaint.
Three health service workers participated in the abuse of two patients while a registered nurse and another health service worker watched without trying to stop it, according to another public record.
State officials won’t say how hospital protocol failed to protect the patients, and it’s unclear why no one else was charged. Sharpe Hospital in Weston is one of two state-owned psychiatric hospitals in West Virginia.
West Virginia State Police of the Weston detachment charged Michael Sean Coleman, whose address is listed in Mount Vernon, Ohio, with strangulation occuring on Sept. 18 in Lewis County. Cpl. L.D. Mohr of the State Police filed the complaint on Oct. 5.
Mohr received a report of abuse of Ethan Pugh, a Sharpe patient who has a traumatic brain injury, by staff from Alisha Meyers, a state adult protective services worker, on Sept. 24, according to the criminal complaint.
Mohr went to the hospital and reviewed video footage from Sept. 18 that showed Coleman push Pugh onto a bed from behind and get on top of him, the complaint states. Mohr wrote that the incident appeared unprovoked, although the camera did not capture the entire incident. Pugh appeared “cooperative,” he wrote.
April Riley, a certified nursing assistant who witnessed the incident, gave a statement, according to the complaint. She said as she walked past Pugh’s room she saw Coleman on top of Pugh with both his hands around Pugh’s neck, the complaint states. Steven Graham, another employee, gave a similar statement, the complaint states.
State health officials with the Office of Health Facility Licensure & Certification visited the facility from Oct. 25- Oct. 27, according to a U.S. Department of Health and Human Services record of the visit. They found that an “immediate jeopardy” complaint about the incident was substantiated, and that the facility had “completed a plan of correction.”
But according to that record, three health services workers abused two patients, while another health service worker and a registered nurse watched without attempting to stop it. Federal health officials say immediate jeopardy refers to a situation in which entity noncompliance has placed the health and safety of recipients in its care at risk for serious injury, serious harm, serious impairment or death.
Five employees, including one registered nurse and four health services workers, were fired, according to the report. Sharpe had also notified adult protective services workers and State Police, the record states.
The record states that the health service worker who was the “ringleader,” apparently Coleman, had been arrested, and the Nurse Aid registry was alerted to his role.
“An education program was developed regarding the definition of abuse and the role of mandatory reporting and filing an APS report immediately,” the record states.” The education was provided to all staff in the hospital from 9/24/21 to 10/15/21.”
In emails, Mohr said no one else was charged in relation to the abuse. Mohr said a Dec. 1 hearing was continued to Dec. 21, but a court employee said Tuesday no hearings for Coleman were scheduled Tuesday. Mohr said he believed attorney Steve Nanners represents Mohr; Nanners did not return a call.
Mohr did not respond to an email Monday and previously declined to answer questions by phone.
In a Nov. 10 email, Lawrence Messina, spokesman for the West Virginia Department of Homeland Security, said Coleman was not currently incarcerated and had never been incarcerated in West Virginia.
In a Dec. 3 email, Christy Flanigan, Lewis County prosecutor said the Dec. 1 hearing was continued on a motion from the defense.
“I’m not sure for what reason,” she wrote. “He apparently had previously signed a waiver of the time period in which to have his preliminary hearing. I do not believe it has been reset as of yet.”
She said to contact Assistant Prosecutor Russ Stobbs for more information; Stobbs did not return a call Monday.
The state Department of Health and Human Resources did not respond to several emailed questions about the incident and denied a Freedom of Information Act request seeking relevant records, citing multiple exemptions related to confidentiality and criminal investigations.
Allison Adler, spokeswoman for DHHR, did send the following response via email:
“The West Virginia Department of Health and Human Resources (DHHR) will not tolerate patient abuse, patient neglect, or patient exploitation at any of its health care facilities. Employees or contract staff who engage in such offensive conduct will be terminated, referred to the appropriate authorities for prosecution, and turned over to the appropriate licensing boards for disciplinary action.
DHHR is committed to protecting and promoting patient safety. While DHHR has a dedicated clinical team, DHHR and independent patient advocates will continue to train DHHR employees and contract staff about patient safety, and DHHR will continue to assist the appropriate authorities in prosecuting persons who compromise patient safety.”
She did not respond to a question about what went wrong allowing the incident to take place in the first place.
Jolynn Marra, interim inspector general for OHLFAC, has not responded to inquiries. “The Office of Inspector General (OIG) provides autonomous, independent and neutral oversight” over DHHR, according to OHFLAC’s website.
Tips, on and off the record, can be sent to: wvtips304 at gmail.com.