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.

TUALITY COMMUNITY HOSPITAL 335 SE 8TH AVENUE HILLSBORO, OR 97123 March 8, 2012
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on review of documentation and interviews, it was determined that the hospital failed to implement an appropriate grievance process which included the recognition and acknowledgement of a grievance, and the provision of written notice of its decision regarding resolution of the grievance to the the complainant, who was the patient's representative, in 1 of 1 patient records reviewed.

Findings:

Patient #1 was a [AGE] year old person admitted on [DATE] to evaluate and treat abdominal pain, and discharged from the hospital on [DATE].

In an interview with the Relief Nursing Supervisor (RNS) on 03/08/12 at 0905 hours in the administrative conference room, the RNS stated that she/received a telephone call from a physician at approximately 1400 hours on 01/13/12. The RNS sated that this physician, MD #1, was the Medical Director for one of the two local Hospice organizations within the community. MD #1 reported that she/he had received a phone call from the adult grandchild of Patient #1, who reported to the physician that Employee #1 had performed a "(genital) examination," and that the grandchild felt that Patient #1 had been sexually assaulted by Employee #1.

The RNS stated that at 1450 hours, the grandchild of Patient #1 called the RNS to report sexual abuse, and that "(he/she) was not specific with me" regarding the allegations. The RNS stated that the grandchild said that Patient #1 was aware that he/she would be calling to report a sexual assault.

In an interview with the Director of Inpatient Services (DIS) on 03/08/12 at 1100 hours in the administrative conference room, the DIS stated that "Each of the stories (from three interviews conducted by several different Hospital staff members) were consistent: (Patient #1) consistently said nothing inappropriate had happened, and (Employee #1, the caregiver who allegedly perpetrated the abuse) consistently said nothing inappropriate had happened. The DIS stated that a formal grievance had not been documented, as Patient #1 stated that no abuse or assault had taken place, and had refused to pursue a complaint about his/her care.

A Hospital policy titled: "Patient Concern, Complaint/Grievance Resolution Policy C-05C" contained the following:
"Definitions
C. Grievance: A written or verbal concern filed by a patient or the patient's designated representative to request the facility formally review a quality of care concerns or neglect concern..."

The Centers for Medicare and Medicaid Services (CMS) defines "patient grievance" in the following way: a formal or informal written or verbal complaint that is made to the hospital by a patient, or the patient's representative, regarding the patient's care, abuse or neglect..."

and

"All verbal or written complaints regarding abuse, neglect, patient harm, or hospital compliance with CMS requirements are considered grievances for the purpose of these requirements."

The Hospital received an allegation of sexual abuse from a family member of a patient, who represented the rights of that patient. The Hospital failed to define this as a grievance, and failed to complete the established requirements in the resolution of that grievance.