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.

Based on interview and review of hospital policy, it was determined that the hospital failed to adopt a policy and procedure that assured all patients' right to be free from all forms of abuse or harassment.

Findings include:

Review of the hospital's Policy and Procedure: "Victims (Potential) Of Neglect, Abuse, or Violence: Identification, Assessment and Intervention for..." revealed the following:

B. Intervention - Staff will:
1. Interview patient alone, asking open-ended, direct questions...
3. Assess patient's safety to return to resident
4. Document findings of physical exam, verbatim statements of patient...
5. Refer for follow-up; i.e., evaluation, counseling, and other measure as appropriate.
6. Provide resources, review options and referrals...."

The policy did not identify which staff would be appropriate to interview patients and what qualifications or training staff should have to conduct potentially sensitive interviews, assess patient's safety to return home, conduct and document an exam, determine appropriate referrals for follow-up or which resources were to be provided to patients.

2. Department of Social and Health Services: an oral report is required within 24-48 hours or immediately if emergent...
For Children & Adults: Hotline - call 1-866-ENDHARM (1-866-363-4276) Washington States toll-free, 24-hour, 7 day-a-week hotline that will connect you directly to the appropriate local office to report suspected child or vulnerable adult abuse or neglect.
3. Police department at 911 for physical assault with a weapon, or obvious crime. Routine reporting of Domestic Violence, sexual or physical assault is not mandatory in Washington State unless a weapon is involved and/or the victim is a child, vulnerable adult or hospitalized patient..."

The policy as written does not identify the Department of Health (DOH) as the regulatory authority for hospitals or that the DOH should be notified of allegations regarding abuse/neglect/exploitation relative to hospitalized patients, whether the patients were adult or children, in-patient or out-patient.

The policy incorrectly stated that reports should be made to the Department of Social and Health Services (DSHS), which does not have regulatory authority relative to hospitals. Discussion was held regarding which reports should be made to the DOH and which reports should be made to the DSHS.

The policy also incorrectly stated "24-hour, 7 day-a-week hotline that will connect you directly to the appropriate local office to report suspected child or vulnerable adult abuse or neglect." The DSHS hotline can receive recorded reports 24 hours a day, 7 days a week, but the hotline is not staffed with operators who "connect you directly to the appropriate local office".

The policy also did not state that other alleged activities against patients should also be reported to local law enforcement, such as theft.

Discussion was also held with the Director of Clinical Care regarding the hospital's interpretation of the definition of "hospitalized patient". Clarification was provided that "hospitalized patient" means any patient who is in the care of the hospital, to include in-patient or out-patient status.