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 documents, it was determined that the hospital failed to adopt and implement a policy and procedure to assure that each patient was free from all forms of abuse or harassment. The hospital's failure to do so placed all patients who needed such protection at risk of not receiving same.

Findings include:

The hospital's policy "Abuse of Children, Adult Dependent or Developmentally Disabled Persons, Reporting of, Role of Nursing" was reviewed. The policy stated:

All nursing employees who have reasonable cause to believe that a child or adult dependent or developmentally disabled person has suffered abuse or neglect shall immediately report such incident, or cause an immediate report to be made, to the proper DSHS department: Adult Protective Services (APS) or Child Protective Services (CPS)...

Adult dependent persons not able to provide for their own protection through the criminal justice system shall be defined as those persons over the age of eighteen years who have been found legally incompetent pursuant to chapter 11.88 RCW or found disabled to such a degree pursuant to said chapter, that is such protection is indicated..."

Discussion was held with the Director, Risk Management and Quality Services (DRMQS) about the definition of vulnerable adults, and that the definition was not consistent with the WAC definition which states:

"72) "Vulnerable adult" means, as defined in chapter 74.34 <> RCW, a person sixty years of age or older who lacks the functional, physical, or mental ability to care for him or herself; an adult with a developmental disability under RCW 71A.10.020 <>; an adult with a legal guardian under chapter 11.88 <> RCW; an adult living in a long-term care facility (an adult family home, boarding home or nursing home); an adult living in their own or a family's home receiving services from an agency or contracted individual provider; or an adult self-directing their care under RCW 74.39.050 <>. For the purposes of requesting background checks pursuant to RCW 43.43.832 <>, it shall also include adults of any age who lack the functional, mental, or physical ability to care for themselves. For the purposes of this chapter, it shall also include hospitalized adults."
The policy also directed nursing staff only to report suspected abuse and neglect. Discussion was also held with the DRMQS about other staff and employees in the hospital who might be mandated reporters, such as physicians, social workers, etc. and how the policy, as written, did not appear to require those people to report.
In addition, discussion was held regarding the agencies to whom the staff was to report suspected abuse and neglect. The policy named only CPS and APS, both divisions of the Department of Social and Health Services (DSHS). Discussion was held about the scope and responsibilities of the DSHS and it's various divisions, as well as the scope and responsibility of the Department of Health (DOH) and when it would be appropriate to report to the DOH.
The hospital's Protocol "Responding to Allegations of Inappropriate Conduct By Staff" was also reviewed. The protocol, which the DRMQS stated was utilized as a policy, directed that:
"4. The complaint should be communicated to Risk Management/Quality immediately. Until the complaint has been reported, no investigation should be initiated..."
The protocol further directed:
"16. If the event is to be reported to the police, this should occur as soon as possible. It should be made clear to the police that an investigation on their part is needed. Security will coordinate interactions with the policy and shall consult with RM [Risk Management] as needed..."
The protocol was discussed with the DRMQS who acknowledged that some situations should be reported to local law enforcement immediately because the investigation of same would be beyond the scope of hospital personnel; however, the protocol did not clarify what those situations might include. Also discussed was how such events were to be processed with "Risk Management/Quality could not be immediately accessed.