HospitalInspections.org

Based on interview and document review, it was determined that the hospital failed to assure that all hospital patients were free from abuse, neglect, harassment and/or exploitation. The hospital's failure to do so placed all patients who were the victims of abuse, neglect, harassment and/or exploitation at risk for unreported and uninvestigated harm.

Findings include:


The hospital's policy "Abuse/Neglect, Reporting Suspected" was reviewed. The policy definition included abuse/neglect and sexual exploitation, but did not include examples of exploitation such as the taking of inappropriate photos or financial exploitation, including theft.

The policy's definition of "dependent adult person" did not include the current Washington Administrative Code definition of vulnerable/dependent adults which states: "vulnerable adult...shall also include hospitalized adults". Reference WAC 246-320-010 Definitions (72).

The policy defined local law enforcement as "Law Enforcement Agency: Police Department, Prosecuting Attorney, State Patrol, Director of Public Safety, or Sheriff". On interview on 8/3/2010, the Chief Nursing Officer (CNO) acknowledged that the definition included personnel/agencies to which staff would not actually report allegations or findings, such as a prosecuting attorney, and that the policy was misleading. With the exception of suspected child abuse, the policy did not state which law enforcement agency should be notified, how, when or under what circumstances. For suspected child abuse, staff were directed to call 911.

The portion of the policy titled "Notification" was incomplete and inaccurate. Discussion was held on 8/3/2010 with the CNO and the Director of Quality Management (DQM) regarding the scope of authority and the roles of the Department of Social and Health Services (DSHS), including the offices of Adult Protective Services and Child Protective Services. Specific discussion was held regarding which settings, such as Adult Family Homes, Boarding Homes, Skilled Nursing Facilities and private homes, received regulatory oversight and from which portion of the DSHS that oversight was provided. Specific examples were provided for when the DSHS should be notified regarding suspicions of abuse, neglect, harassment and/or exploitation.

Discussion was also held regarding the scope of authority and the role of the Department of Health (DOH). Specific discussion was held regarding which health care organizations received regulatory oversight from the DOH, and examples were given provided for when the DOH should be notified of suspicions of abuse, neglect, harassment and/or exploitation.

The policy did not contain directions for how to proceed with identification and reporting of suspected abuse, neglect, harassment and/or exploitation when the alleged perpetrator was internal to the hospital: employees, volunteers, clergy, visitors or other patients. The CNO and the DQM confirmed that the hospital had a policy for reporting allegations of abuse/neglect, harassment and or exploitation by physicians, and acknowledged that any other suspected perpetrators would not be included in either policy.

The hospital's failure to develop and implement complete and accurate policies for the identification and reporting of suspected abuse/neglect, harassment and/or exploitation of patients, placed all victims of such acts at risk for unreported and uninvestigated harm.