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.

THOMAS JEFFERSON UNIVERSITY HOSPITAL 111 SOUTH 11TH STREET PHILADELPHIA, PA 19107 Dec. 10, 2019
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on review of facility policy, documents, documentation, medical record (MR), and interview with staff (EMP) it was determined the facility failed to conform to Federal regulations.

Thomas Jefferson University Hospitals was not in compliance with the following Federal regulations::

482.13(a) Notice of Rights
(a)(2)(iii) In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

This regulation is not met as evidenced by:

Based on review of facility policy, documents, documentation, medical record (MR) and interview with staff (EMP) it was determined that the facility failed to provide a written notice of its decision, that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process and the date of completion, to the complainant in one of one medical records reviewed to address the grievance (MR1).

Findings include:

Review of facility policy "Patient Rights and Responsiblities" last revised February 9, 2017, revealed "POLICY:...Thomas Jefferson University Hospitals (TJUH) recognizes that patients have certain rights in their relationship with the hospital and their physicians. These rights also apply in the case of neonates, children and adolescents and to their families and legal guardians. It is our goal to provide medical care that is effective and considerate within our capacity, mission and philosophy, and that is compliant with applicable law and regulation, as described in the following paragraphs. We recognize our ethical responsibility to the patients and community we serve and therefore operate and provide all services according to a code of conduct. ...Patients have the right to be treated in a dignified and respectful manner by all TJUH personnel. ...Patient have the right to be cared for by staff educated about patient rights and their role in supporting those rights."

Review of facility policy"Patient Complaints/Grievances Management Of" last revised September 15, 2017, revealed "A grievance is always: Verbal complaints that cannot be resolved at the time of or within a reasonable time frame by staff present or postponed for later resolution, are referred to other staff for later resolution, require in-depth investigation, and/or require further actions for resolution. ...2. Grievances about situation that could endanger the patient, such as neglect or abuse, will be reviewed in an expedited manner as warranted by the nature of the situations and should involve the Office of Risk Management/Patient Safety. 3. Grievances should be resolved within 7 (seven) business days of receipt and a written response provided to the complainant."

Review on July 18, 2019, of facility document dated February 11, 2019 recorded by EMP3, revealed "Unknown Jefferson male employee sexually assaulted complainant in recovery room by caressing her boobs (breasts), kissing her neck and ears, offender transported complainant to her room and continued with previous stated actions. Witness [name redacted-EMP2]."

Review on July 18, 2019, of facility documentation (email correspondence) from EMP5 dated February 11, 2019, at 11:27 AM revealed " Subject Assault-Transport. Hello, I received a call from [name redacted-EMP2] in Neurosurgery at 901 Walnut...[MR1] patient ...is there and is asking to speak to someone regarding making a report about being assaulted by a transporter on 1/29/19 in the Gibbon building."

Review on July 18, 2019, of MR1 progress note dated February 11, 2019, at 11:00 AM by EMP4 revealed "Note: During the intake, MR1 described an assault that occurred to her while she was in the hospital. This was immediately reported to the office administration..."


Review on July 18, 2019, of facility documentation (email correspondence) dated February 11, 2019, at 11:44 AM revealed "Hi [name redacted] : [name redacted] EMP6 is aware of this, as per the email you will see below. I filled her in on some of the additional details. This is correctly investigated by Security, so they are taking the lead on looking into this." Thanks..."

An interview conducted on July 18, 2019, at 11:50 AM with EMP6 confirmed that a report for sexual assault was received by the facility on February 11, 2019, for an incident that occurred on January 29, 2019, for MR1. Further interview confirmed that the facility had not provided a written response within 7 days to MR1 as per the facility's policy. In addition, EMP6 confirmed the incident required additional resources to investigate the details and that the sexual assault report was considered a grievance.