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 document review the hospital failed to report an incident of verbal and physical abuse by an employee towards a patient (Patient #1) to local law enforcement when the hospital was made aware of the incident.

Failure to report allegations of abuse to the proper authoritities in a timely manner puts all patients at risk for receiving care from a health care professional that may be abusing patients.

Findings included:

1. On 06/25/19 at 10:00 AM, the investigator interviewed a contact (Contact #1) for Patient #1. The contact stated the incident on 08/03/19 was not reported to local law enforcement by the hospital. The incident was reported by the Department of Social and Health Services (DSHS) worker to Child Protective Service (CPS) after the patient's mother had informed them of the incident with the Speech Language Pathologist (SLP). CPS then reported the incident to local law enforcement.

2. Document review of the hospital policy titled "Recognition And Treatment of Abuse and Neglect", approved 08/20/18 showed that all incidents of suspected abuse and neglect were to be investigated and reported to local law enforcement.

3. Review of Patient #1's medical record showed that:

a) On 08/03/18 Patient #1 was seen by the SLP (Staff #1) for therapy.

b) On 08/08/18 the SLP wrote an addendum to the patient's visit on 08/03/18. The addendum showed that the SLP became angry with Patient #1 and placed their hands on Patient #1's upper chest. The SLP documented that they informed Patient #1's mother that was out in the waiting room of the incident.

4. Review of the hospital investigation of the incident showed that:

a) The SLP had apologized to Patient #1's mother on 08/03/18. The SLP had alerted their Director regarding their interaction with the patient on the day it occurred.

b) The SLP's supervisor met with the mother of Patient #1 on 08/13/18 to discuss the incident.

c) On 09/04/18 the Chief Patient Care Executive (CPCE) met with Patient #1's mother about the incident. It was reported to the CPCE that the SLP had reported to the mother that the SLP had lost it and called the patient a "B... and had placed their hands on Patient #1's chest.

d) The SLP had no prior complaints about their care to patients. The SLP was sent to classes on dealing with challenging patient behaviors.

5. On 07/16/19 at 8:30 AM, the investigator interviewed the Director of Quality and Risk Management (Staff #2). Staff #2 stated the incident was investigated by the hospital. The hospital had sent Staff #1 to classes on dealing with challenging patient behaviors. The SLP (Staff #1) was only allowed to perform therapy in a room with the windows open so they could be plainly viewed and monitored in their interactions with patients. The hospital did not report the incident to the local police as stated in the hospital policy.

6. On 07/16/19 at 12:00 PM, the investigator interviewed the Interim Chief Nursing Officer (Staff #3). Staff #3 verified the above information