The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

ADVENTIST HEALTHCARE WASHINGTON ADVENTIST HOSPITAL 7600 CARROLL AVENUE TAKOMA PARK, MD 20912 Aug. 12, 2014
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview of the hospital staff (licensed nursing floor staff and Risk Management Staff), and review of the hospital's grievance log, a patient's closed medical record, and the hospital's alleged patient abuse investigation, it was determined that the hospital staff failed to document the allegation of abuse (requiring extensive investigation) on their grievance log as required.
The findings were:
1. A review of Patient #1's closed medical record revealed a [AGE] years old was admitted on [DATE] from an assisted living facility (ALF) for a change in mental status. The patient remained in the hospital until 05/27/14 at 16:41(4:41PM) when the patient was discharged back to the ALF. The ALF called the hospital on [DATE] at approximately 3pm (over 20 hours after discharge) to report that the patient had been found with : redness around her vaginal area, bruises on the ankles, an open bedsore on the buttocks, scratches on the chest, and a hand print on the face. The patient's transfer diagnoses included: dementia, hypertension, rhabdomyolysis ( breakdown of muscle tissue with toxic substances released into the blood stream, causes ranging from trauma or laying in one position for a long period of time), and urinary tract infection.

2. Observation of the hospital's Grievance Log on 07/17/14 during the Patient Rights COP review revealed that the patient who incurred the alleged abuse was not listed on the hospital's Grievance log, even though, such a situation by the CMS definition in regulation describes abuse as a grievance. Interview of the Risk Manager [PS] on 07/17/14 confirmed that the allegation was not documented on the grievance log. The Risk Manager revealed that there was an unawareness that this allegation should have been listed on the grievance log since a letter of response would not be sent to the complainant (the ALF).

3. Observation and review of the hospital's Grievance Policy and Procedure(#5977, revised 12/13) titled "Patient Complaint And Grievance Management", Section :Tracking, Trending, and Reporting Complaint Data, #2" stated that all patient issues, concerns, complaints, and grievances are tracked on the Complaint Grievance Log. The hospital RM staff failed to follow their own policy as noted above.

While the abuse allegation could not be substantiated either on the part of the hospital investigation or during the conducted on-site federal investigation, failure by the hospital staff in not documenting the abuse allegation on the Grievance Log, failed to follow their own "approved grievance process." Consistent log entry and maintenance provides the hospital a ways and means to determine which grievances require immediate investigation and action or those that have to be processed and investigated with an anticipated longer time frame.