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Based on the review of hospital policy and procedures, documentation and interviews with hospital staff, it was determined that the hospital failed to inform parents/primary caregiver of all pediatric patients of their right to inspect and obtain a copy of health information from the medical record within a reasonable time frame.

Findings include:

The following policy/procedure was reviewed, "Patient's Rights," effective 10/07/2010. The policy reflected, "12. a. the patient and/or patient's legally designated representative/surrogate has access to the information contained in the patient's medical record, within the limits of the law."

The Doernbecher Children's Hospital brochure titled, "Welcome to OHSU Doernbecher Children's Hospital" dated Aug. 2012, was reviewed. It was determined that the hospital failed to utilize the brochure to inform the parents/primary caregivers of pediatric patients of their right to inspect and obtain a copy of health information from the medical record per this regulation and hospital policy.

An interview was conducted with Interviewee G, the Director of Patient Relations, on 02/26/2013 at 1215. He/she confirmed that the hospital failed to inform parents/primary caregivers of children admitted to Doernbecher Children's Hospital, that they have a right to access the patient's medical record within a reasonable time frame.

A team of State Fire Marshals conducted an onsite Fire & Life Safety Survey as part of the complaint survey.

Based on observations, documentation review, and interviews with hospital staff, the State Fire Marshals determined that the hospital failed to ensure that the physical environment was constructed, arranged, and maintained to ensure the safety of patients. The hospital failed to respond appropriately to an actual fire incident. Required inspections of fire alarms, sprinklers, doors, fire extinguisher, and generators were not conducted as required; and fire drills and in-service trainings were not conducted as required. The cumulative effect of these systemic problems resulted in an Immediate Jeopardy situation and a threat to the health and safety of patients and staff. Findings include:


The facility failed to demonstrate appropriate response to an actual fire incident and includes the following:

Failure to clear corridors, activate alarm system, initiate overhead " code red " paging to summon additional staff and warn building occupants, relocation of patients from the smoke compartment of the fire to an adjacent unaffected smoke compartment, contain the fire by closing doors, during the actual fire incident,

Failure to provide quarterly fire drills on each shift, and annual fire and life safety in-service training for all staff in the facility to ensure adequate response in actual events.

Failure to properly install and maintain required life safety systems within the facility including fire alarm, sprinkler, generator, extinguishers, and doors.


Refer to the detailed findings listed at K tags K12, K18, K29, K38, K45, K46, K48, K51, K52, K56, K62, K64, K72, K75, K76, K144, K147, and K211 on Form CMS-2567 issued by the Office of the State Fire Marshal.