HospitalInspections.org

Based on interview and review of grievance files, it was determined that the hospital failed to ensure that the personal privacy of all patients was protected. The hospital's failure to do so resulted in 3 of 9 grievance response letters containing personal information being sent to parties other than the patients. This failure deprived the 3 patients of their right to personal privacy and placed all patients of the hospital at risk for same.

Findings include:

On 1/28/2013, the hospital's grievance log was reviewed. Nine (9) files were selected for review based on the issues identified in the log. The files selected for review included issues such as patient complaints about sexual and/or physical assaults, call lights not being answered in a timely manner, patients not being cleaned promptly after incontinent episodes and long waits for pain medication.

Findings include:

Current Patient #7
The hospital's response letter to the grievance lodged by the patient contained personal information about the patient, who had reported a sexual assault. The response letter was addressed to someone other than the patient. The Director of Quality Management (DQM) stated that the patient had been sent a copy of the letter, but acknowledged that the letter did not contain evidence, such as an address or "cc", that the patient had been included in the communication.

Former Patient #1
The patient had reported a sexual assault to a concerned party, who in turn reported the allegations to the hospital. The hospital's response letter to the grievance lodged by the patient contained personal and detailed information about the patient. The hospital's response letter was addressed to the concerned party and did not contain evidence, such as an address or "cc", that the patient had been included in the communication. The former patient was alert and able to communicate when interviewed by the investigator on 1/24/2013.

Former Patient #2
The patient had reported a physical assault to the hospital. The hospital's response letter to the grievance lodged by the patient contained personal and detailed information about the patient. The hospital's response letter was addressed to a concerned party and did not contain evidence that the patient had been included in the communication. Although the patient died shortly before the investigator was onsite, the letter to the concerned party was dated prior to the patient's death.

The hospital's letters of response to the allegations contained detailed, personal information about the patients, and were sent to third parties, even though all 3 patients had been able to communicate their allegations of sexual/physical abuse. The hospital's detailed letters, sent to parties other than the patients, deprived all 3 patients of their right to personal privacy.

Review of the hospital's policy and procedure (P&P) "Patient Rights and Responsibilities" revealed the following:

"PATIENT/FAMILY/SURROGATE RIGHTS...
7. The patient has the right to personal privacy..."

Attached to the P&P was a list entitled "Washington State Specific Patient Rights". Review of that list revealed the following listed as a patient right:
Each patient has a right to:
"...Confidentiality, privacy..."

The hospital's failure to follow it's own policy and procedures regarding patients' rights to privacy and confidentiality resulted in 3 patients not having their privacy and confidentiality protected, and potentially placed all patients of the hospital for the same loss of rights.

Based on interview, review of medical records, review of hospital policies and internal documents, it was determined that the hospital failed to assure that all patients received care in a safe setting for 5 of 7 current patients and 1 former patient of the hospital.

The hospital's failure to do so resulted in the 6 interviewed patients reporting that they did not feel safe and/or did not feel that their care needs were met in a timely manner.

Findings include:

Current Patients:

Patient #1
Patient #1 was interviewed on 1/24/2013. The patient stated that her/his nurse call light was not always answered promptly. S/he stated that the call light was usually answered via the intercom system. The patient was on a ventilator and could not speak above a whisper; therefore could not be heard via the intercom.

The patient's plan of care was reviewed with a staff nurse, in the presence of the hospital administrator, the Chief Clinical Officer and the Director of Quality Management. The plan of care directed staff to go into the room to answer the call light.

Patient #2
Patient #2 was also interviewed on 1/24/2013. The patient stated that sometimes it was "a long time" before the nurse call light was answered. S/he also stated that some of the nurses were "rude" to her/him and didn't always seem to know her/his current plan of care.

The patient stated that s/he thought there was "tension" with the nursing staff, and that the nursing staff was "short-handed" because s/he could hear equipment beepers going off for long periods of time. The patient also stated that on one occasion, s/he had been in the bathroom when a staff person came in to talk with him/her. When the staff person did not see the patient in the room, the patient heard the staff person complain about having to "gown up" [infection control precautions were in place for the patient] twice to visit the patient, only to find the patient unavailable.

The patient also stated that some times it was "hard" to communicate with the staff who didn't speak English as a first language. S/he stated that s/he thought the language difference might also make it difficult for the nurses to communicate accurately with the patient's physician.


Patient #4
Patient #4 was interviewed on 1/24/2013. The patient stated that nurse call lights were not answered quickly. When asked if s/he thought s/he was receiving good care, the patient indicated "so so", by tipping her/his flattened hand back and forth. When asked if s/he had adequate pain control, the patient stated "when they show up". The patient had a tracheostomy and had a "trache collar" in place. The patient could only speak in a whisper and wrote most responses on a piece of paper.

The patient's plan of care was reviewed with a staff nurse, in the presence of the hospital administrator, the Chief Clinical Officer and the Director of Quality Management. The plan of care did not specifically mention the patient's communication challenges as they might relate to answering questions on the intercom.


Patient #5
Patient #5 was interviewed on 1/24/2013. The patient was noted to have significant mobility limitations. The patient could not speak above a whisper and was assisted with communication by a third party. The patient stated that when s/he was admitted to the hospital, the hospital was "like a ghost town" and the person who had accompanied the patient had to go look for staff.

The patient stated that on the second day s/he was in the hospital, s/he saw no nurses for two and a half hours after the shift changed. Her/his nurse call light was too far away to be reached, and s/he had no way to call for help.

The patient also stated that the nurses were "abrupt" when moving her/his limbs and that caused the her/him pain. The patient stated that on one occasion when s/he asked the nurse for pain medication, s/he was told s/he "did not need" any pain medication.

The patient stated that a concerned third party had talked to the hospital administrator about the rough handling and lack of pain medication. S/he stated that the administrator had immediately talked with the nursing staff about the patient's complaint and the nurses were reportedly "unaware' of the patient's pain issues.

The patient stated that on one occasion, her/his nurse call light was on for one and a half hours and was never answered, although s/he could hear staff at the nurses' station, just a short distance away from her/his room.

The patient also stated that s/he can't talk above a whisper and when the staff answered the nurse call light, they often answered the light via the intercom. The patient stated that s/he is unable to respond to the questions via the intercom, but no one follows up the intercom questioning by going into her/his room.

The patient stated that on one occasion, the call light was answered via the intercom, but no one came into the room. Because of the lack of nursing assistance, the patient was subsequently incontinent of bowel. The patient stated that when the nursing staff finally did come in to the room and provided hygiene, the full bedpan was then placed under her/his bed and left there.

The patient became tearful during the interview and stated that s/he believed the staff "did not care". S/he stated that s/he did not believe s/he was getting the nursing care s/he "deserved". One of the reasons, s/he stated, was that when s/he expressed having pain during care, s/he did not receive a response from the staff. The patient stated that s/he felt "very vulnerable" now because s/he was unable to do anything for her/himself.

Witness A
Witness A was interviewed on 1/24/2013. The witness stated that s/he was frequently in the hospital to visit [Patient #5]. S/he also stated that the patient's call light was not answered promptly and was frequently answered via the intercom, but staff did not always come into the room. S/he stated that the patient could not speak above a whisper and was unable to move and was completely dependent upon the nursing staff for all needs.

Witness A also stated that s/he had observed a former roommate of the patient "begging for help" while that patient's call light went unanswered. S/he stated that the patient was calling out for help, but got no response until Witness A went to the nurses' station to get help for the patient.

Witness B
Witness B was interviewed on 1/24/2013. The witness was also a concerned party who stated s/he had known the patient for 20 years. The witness stated that the patient reported that s/he felt like s/he is "...being punished for getting the nurses in trouble". The witness stated that s/he spoke with the hospital administrator about the patient's concerns.

Witness C
Witness C was interviewed on 1/30/2013. The witness stated that s/he had visited the patient when the patient was first admitted to the hospital. The witness stated that s/he observed "rough nursing". When asked to describe the "rough nursing", the witness stated that the nurses hurt the patient by picking up the patient's limbs without supporting the joints. S/he stated that s/he personally observed "one RN pick up an arm and 'free move' it without support". When the patient complained of pain during the events described, the nurses either denied that the patient was in pain, or stated that there was nothing they could do about it.

The witness stated that on one occasion, s/he came to the hospital to find a "rope of snot" hanging out of the patient's nose and extending down the side of the patient's face, with the nurse call bell out of reach. S/he stated that the patient could not call out, but had attempted for attract attention by clicking her/his tongue for 2 hours, until the patient's tongue was sore. S/he stated that when s/he arrived at the hospital, the patient was so distraught that s/he was in tears.

The witness also stated that on one occasion s/he observed the patient ask for pain medication and then wait for one and a half hours for the medication. S/he stated that the nurse told the patient the medication was not "due" until 9 am, but the patient did not receive the medication until 10:15 am.

The witness stated that on another occasion she witness a "bedpan disaster". S/he stated that the patient reported that s/he had repeatedly asked for a bedpan, but no one came into the patient's room. As a result, the patient was eventually incontinent of stool. The witness stated that when s/he arrived at the hospital, there was a bedpan "full of poop" on the floor under the patient's bed. The witness stated that s/he personally removed the bedpan to the bathroom.

The witness stated that most of the male nurses were kind and gentle, but the female nurses tended to be rougher. S/he stated that one female nurse had provided peri-care [cleaning of the genital area] and used cold water.

Witness D
Witness D was interviewed on 2/6/2013. The witness stated that s/he had observed the patient moaning and calling out for help, but no one came to the patient's room. The witness stated that the nurses told her/him that they can not turn off the call light from the desk, but they also do not always come into the room after they answer the call light via the intercom. She stated that some times the call light would be answered via the intercom, but often whoever answered the light would "just hang up".

The witness stated that the patient reported that s/he was "afraid the nurses were going to punish [her/him] because the patient had identified the nurses who had been rough. The patient thought that the "pay back" was ignoring the patient's call light, and the witness stated s/he believed that because s/he would often have to push the call light many times to get help.

The witness stated that on occasion, s/he would attempt to get the nurses to care for a former roommate of the patient. S/he stated the patient would call out for help, but when the witness would ask the nurses for help, they would make comments such as "...[s/he] is just talking in [her/his] sleep".

The witness stated that s/he observed "rough handling" of the patient. When asked to describe what s/he saw, the witness stated that sometimes when the nurses were handling the patient, the patient's face would turn red and s/he would start to cry but the nurses "didn't pay attention".

The witness also stated that because of concerns for the patient's safety, concerned others always stayed with the patient. S/he stated that when people would come to visit the patient, staff at the desk could be hear to make comments such as "next shift coming on".

The witness stated that the patient was afraid that s/he would be punished for identifying the nurses, and that the punishment would be in the form of not answering her/his call light.

The patient's plan of care was reviewed with a staff nurse, in the presence of the hospital administrator, the Chief Clinical Officer and the Director of Quality Management. The plan of care directed staff to place the nurse call light near the patient's head, but did not specifically direct staff to go into the room when the call light was activated.

Patient #6
Patient #6 was interviewed on 1/24/2013. The patient stated that her/his nurse call was not always answered promptly. S/he stated that on one occasion s/he had to wait 3 hours to receive pain medication.

Former Patient #1
Former Patient #1 was interviewed on 1/24/2013. The patient had been discharged from the hospital and was receiving a different level of care. S/he stated that there had been an incident in the hospital and s/he was "upset that it had to happen". The patient stated that s/he had felt "revenge upstairs [in the hospital].

When asked to describe what had happened in the hospital that had upset her/him, the patient stated that during peri-care, s/he had been inappropriately touched. The patient stated that during the peri-care, the nurse had said the word "masturbation". The patient also demonstrated with her/his right hand in the air, what actions had allegedly occurred.

The patient stated that s/he could identify the aide who allegedly performed the actions, but would not because it would be "throwing mud". The patient also stated s/he did not report the allegation to the hospital because "...I know about retaliation. I know they can hurt you."

In addition to patients and concerned third parties, the hospital Administrator, Chief Clinical Officer (CCO) and Director of Quality Management were interviewed throughout the 3-day onsite investigation. The Administrator and CCO both stated that the hospital had modified the nurse call light system so that call lights could not be turned off from the nurses' station.

The CCO stated that s/he believed call lights were answered in a prompt manner because s/he had personally visited the floors to observe how lights were answered.

On 1/30/2013, the CCO also stated that patients who are on ventilators and/or are being weaned off of ventilators are also on telemetry [heart monitoring], which is monitored at the nurses' station. S/he stated that those alarms are set to alarm if patient heart rates/respiratory rates vary from pre-determined levels.

Review of the hospital's policy and procedure (P&P) "Patient Rights and Responsibilities" revealed the following:

"PATIENT/FAMILY/SURROGATE RIGHTS...
8. The patient has the right to care in a safe setting...
13. The patient has the right to considerate and respectful care..."

Attached to the P&P was a list entitled "Washington State Specific Patient Rights". Review of that list revealed the following listed as a patient right:
Each patient has a right to:
"Be treated and cared for with dignity and respect...security..."

The hospital's failure to follow it's own policy and procedures regarding patients' rights to care in a safe setting, resulted in 5 current patients feeling unsafe and insecure with the care provided in the hospital, and potentially placed all patients of the hospital for the same experience.


Reference citation written at Tag A0145

Based on interview, review of policy and review of internal hospital documents, it was determined that the hospital failed to develop and implement a policy and procedure that assured that all patients were free from abuse and neglect.

The hospital's failure to develop and implement an accurate policy and procedure on the reporting of abuse and neglect of patients resulted in the delayed investigation of 2 cases by the DOH. The hospital's failure also resulted in a delayed investigation of 1 case by local law enforcement. The hospital's failure also potentially placed all patients in the hospital at risk not having timely investigation of allegations of abuse/neglect/exploitation.


Findings include:

Current Patient #7
The patient was unavailable for interview during the onsite investigation. The Director of Quality Management (DQM) was interviewed about the alleged sexual assault reported by the patient.

The DQM stated that the patient had been unable to speak, but was able to use a "black man, penis, vagina" on the board and then spelled out "Nov". The patient then reportedly indicated that s/he had not seen that person since the incident.

On 1/23/2013, the Seattle Police Detective who had interviewed the patient stated to this investigator that the case was closed as "unfounded" because the patient was "self contradictory at times". The Detective stated that what was described to her/him was "physically impossible", but s/he thought "something happened that upset the patient", but s/he did not know what it was.

Former Patient #1
Former Patient #1 was interviewed on 1/24/2013. The patient had been discharged from the hospital to a lower level of care. S/he stated that there had been an incident in the hospital and s/he was "upset that it had to happen". The patient stated that s/he had felt "revenge upstairs [in the hospital].

When asked to describe what had happened in the hospital that had upset her/him, the patient stated that during peri-care, s/he had been inappropriately touched. The patient stated that during the peri-care, the nurse had said the word "masturbation". The patient also demonstrated with her/his right hand in the air, what actions had allegedly occurred.

The patient stated that s/he could identify the aide who allegedly performed the actions, but would not because it would be "throwing mud". The patient also stated s/he did not report the allegation to the hospital because "...I know about retaliation. I know they can hurt you." The patient stated that s/he had told a concerned third party about the allegations and the third party had reported the

The DQM stated that the alleged sexual assault had not been reported to local law enforcement at the patient's request and referred to the hospital's policy on reporting of assault allegations. After the onsite investigation commenced, the hospital did report the allegations to local law enforcement.

The DQM stated that s/he had received a call from a police department supervisor who said that a report would not be written because the patient had been interviewed by the police department and did not want a report written.

Former Patient #2
The former patient died before the Department of Health investigation began. The Chief Clinical Officer (CCO) and the Director of Quality (DQM) Management stated that a family conference had been held with the patient, with the patient's family member present. The patient reported that s/he had been physically abused. The patient described the abuse as a staff person, a "night shift nurse" putting their hand on the patient's chest and telling the patient to "stop calling" [interpreted by hospital staff to mean stop using the nurse call light].

The CCO and DQM stated that the incident had been reported to local law enforcement and to the Department of Health. The DQM stated that Seattle Police had interviewed the patient, in the presence of a hospital house supervisor and the patient's family member. The DQM stated that s/he had called the police department to follow up on the case, and was told that the victim declined to press charges and a report would not be written.


The Department of Health (DOH) was notified that Current Patient #7 had alleged that s/he had been sexually assaulted in the hospital. When the onsite investigation began, on 1/23/2013, the DQM identified 2 other patients who had alleged sexual/physical abuse. A phone call was made to the DOH Investigations Supervisor who confirmed that the DOH had not received the 2 additional reports.

On 1/24/2013, a phone call was made to the Department of Social and Health Services (DSHS) complaint intake to determine if the reports may have been inadvertently made to the wrong department. The intake supervisor did not immediately find those reports.

On 1/24/2013, after further onsite investigation, it was determined that the 2 additional reports of sexual/physical abuse had, in fact, been reported to the DSHS, not the DOH, as required by law.

The hospital's policy and procedure (P&P) "Abuse of Patient, Elder, Child by Staff Identification - Response and Reporting" was reviewed. The review of the document revealed multiple directives to notify the Department of Social and Health Services, as opposed to the Department of Health, which has authority for regulatory oversight in hospitals in Washington State.

The P&P also directed staff that "A mandated reporter is not required to report to a law enforcement agency, unless requested by the injured vulnerable adult or his/her legal representative or family member, an incident of physical assault between vulnerable adults that causes minor bodily injury..." The DQM referred to that statement during discussion of reporting requirements, and further discussion was held that the allegations under investigation were not between vulnerable adults.

Review of the hospital's policy and procedure (P&P) "Patient Rights and Responsibilities" revealed the following:

"PATIENT/FAMILY/SURROGATE RIGHTS...
9. The patient has the right to be free from all forms of abuse or harassment..."


Attached to the P&P was a list entitled "Washington State Specific Patient Rights". Review of that list revealed the following listed as a patient right:
Each patient has a right to:
"Be treated and cared for with dignity and respect...security...
Be protected from abuse and neglect"