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.

EASTERN STATE HOSPITAL 850 MAPLE STREET - P O BOX A MEDICAL LAKE, WA Dec. 22, 2015
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on review of facility policies and staff interviews, the hospital failed to ensure that staff members implemented the hospital policy and procedure to report actual or suspected patient abuse for 6 of 8 employees interviewed.

Employees are "mandated reporters" and must report "all incidents of known or suspected abuse..." as required by Code of Federal Regulations (42 CFR 482.13(c)(3)).

Failure to implement established guidelines for mandatory reporting risks physical and psychological harm for patients, loss of dignity, and is a violation of patient rights.

References:
42 CFR 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment.

Findings:
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1. The hospital's policy and procedure entitled "Patient Abuse Procedure for Reporting" (Reviewed 9/2015) stated that each hospital employee is a "mandated reporter" meaning "reporting requirements apply to all incidents of known or suspected abuse..."; and, "Any employee witnessing an incident of patient abuse or having cause to suspect the unreported occurrence of patient abuse must report the incident...immediately."
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2. Patient #7 was admitted on [DATE] with diagnoses including schizoaffective disorder and bipolar disorder. The hospital administrative staff received an employee email (from MHT #1) dated August 10, 2015 alleging physical abuse of Patient #7 by RN #1. Interviews with MHT #1 revealed that s/he believed the incident occurred on June 1, 2015 (over 2 months before the email to administration).
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3. MHT #1 was interviewed on 11/25/2015 at 10:15 a.m. and again on 12/21/2015 at 2:45 p.m. When asked why s/he didn't report the incident immediately to the state Department of Health as a mandated reporter, s/he stated s/he was not aware that s/he should and didn't know how to make a report to the State Department of Health. When asked about hospital training, s/he stated that there was some training during orientation about recognizing and reporting patient abuse to their immediate supervisor, and a required annual review of policies that included reporting abuse, but staff members didn't have sufficient time to read the documents and usually just read as much as time allowed, signed them and turned them in.
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4. Another employee (MHT #5) was interviewed on 12/21/2015 at 3 p.m. When asked about training received on how to recognize and report patient abuse, s/he responded that staff are to "follow the chain of command," and didn't know about reporting suspected abuse to the State Department of Health.
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5. Similar responses about not knowing how to report related to patient abuse were found on interviews with 4 other hospital staff members (MHT #2, MHT #4, MHT #6, and RN #4).
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The hospital failed to implement effective staff training so that staff members knew how to report incidents of patient abuse to the hospital and to the State Department of Health.