A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 08/04/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

504016 04/07/2020STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL

TACOMA, WA 98405

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 000 INITIAL COMMENTS A 000

.

MEDICARE COMPLAINT INVESTIGATION

The Washington State Department of Health

(DOH) in accordance with Medicare Conditions of

Participation set forth in 42 CFR 482 for

Hospitals, conducted this complaint investigation.

Investigation dates: 04/01/20 - 04/03/20 &

04/07/20

Intake number: #98867

Examination number: 2020-5203

The investigation was conducted by:

Investigator #2

Investigator #3

Investigator #11

DOH staff found the facility in substantial

compliance with 42 CFR 482.12, Governing

Body, 42 CFR 482.13 Patient Rights, 42 CFR

482.23 Nursing Services, and 42 CFR 482.42

Infection Prevention and Control and Antibiotic

Stewardship Programs, Conditions of

Participation except those standard-level

deficiencies listed below.

.

A 175 PATIENT RIGHTS: RESTRAINT OR

SECLUSION

CFR(s): 482.13(e)(10)

The condition of the patient who is restrained or

secluded must be monitored by a physician, other

licensed practitioner or trained staff that have

A 175

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

06/02/2020

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that

other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days

following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14

days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued

program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete G1XU11Event ID: Facility ID: 013299 If continuation sheet Page 1 of 5

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 08/04/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

504016 04/07/2020STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL

TACOMA, WA 98405

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 175 Continued From page 1 A 175

completed the training criteria specified in

paragraph (f) of this section at an interval

determined by hospital policy.

This STANDARD is not met as evidenced by:

.

Based on record review, interview, and review of

the hospital's policies and procedures, the

hospital failed to ensure that staff members

followed the hospital's seclusion policy and

procedure for documentation in 1 of 3 seclusion

records reviewed (Patient #301).

Failure to follow established policies and

procedures places patients at risk of physical and

psychological harm and possible violation of

patient rights.

Findings included:

1. Document review of the hospital's policy titled,

"Use of Seclusion and Restraint," no policy

number, approved 10/19, showed that staff will

assess the patient for readiness to discontinue

seclusion at regular intervals to ensure the

patient's safety. The intervals between

assessments should not be longer than 15

minutes.

2. On 04/03/20 at 8:30 AM, Investigator #3 and

the Chief Nursing Officer (Staff #301) reviewed

the medical records of three patients who were

placed in seclusion during their hospitalization.

The review showed that Patient #301 was placed

in seclusion for kicking and banging on walls at

11:23 AM on 03/16/20. The patient was released

from seclusion on 03/16/20 at 2:25 PM. The

review showed no documentation on the

seclusion observation monitoring flowsheet to

indicate that staff members had assessed the

FORM CMS-2567(02-99) Previous Versions Obsolete G1XU11Event ID: Facility ID: 013299 If continuation sheet Page 2 of 5

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 08/04/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

504016 04/07/2020STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL

TACOMA, WA 98405

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 175 Continued From page 2 A 175

patient from 1:45 PM until 2:25 PM, a period of 40

minutes.

3. At the time of the record review, the Chief

Nursing Officer (Staff #301) acknowledged that

no documentation could be found for that period

of time.

.

A 405 ADMINISTRATION OF DRUGS

CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2)

(1) Drugs and biologicals must be prepared and

administered in accordance with Federal and

State laws, the orders of the practitioner or

practitioners responsible for the patient's care as

specified under §482.12(c), and accepted

standards of practice.

(i) Drugs and biologicals may be prepared and

administered on the orders of other practitioners

not specified under §482.12(c) only if such

practitioners are acting in accordance with State

law, including scope of practice laws, hospital

policies, and medical staff bylaws, rules, and

regulations.

(2) All drugs and biologicals must be

administered by, or under supervision of, nursing

or other personnel in accordance with Federal

and State laws and regulations, including

applicable licensing requirements, and in

accordance with the approved medical staff

policies and procedures.

This STANDARD is not met as evidenced by:

A 405

.

Based on record review, interview, and review of

hospital policy and procedures, hospital staff

failed to provide accurate documentation of

FORM CMS-2567(02-99) Previous Versions Obsolete G1XU11Event ID: Facility ID: 013299 If continuation sheet Page 3 of 5

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 08/04/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

504016 04/07/2020STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL

TACOMA, WA 98405

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 405 Continued From page 3 A 405

administered medications in the hospital's

electronic Medication Administration Record

(eMAR) for 2 of 5 patient records reviewed

(Patients #302, #303).

Failure to provide accurate documentation in the

eMAR, of the medications patients received risks

medication errors and patient harm.

Findings included:

1. Document review of the hospital policy and

procedure titled, "Medication Administration and

Documentation: General Guidelines," no policy

number, approved 10/19, showed that the

licensed staff member who administers the

medication shall record the administration in the

patient's electronic medication administration

record (eMAR) after the medication is given. It

also showed that staff should document the time,

route, and any other specific information as

necessary.

2. On 04/02/20, Investigator #3, the Chief Nursing

Officer (CNO) (Staff #301), and the Director of

Quality (Staff #302) reviewed the electronic

medication administration records (eMARs) of

five patients. The review showed:

a. Patient #302 was to receive Chlorpromazine 25

mg (an antipsychotic medication) daily at 8:30

AM. The eMAR on 03/30/20 showed the patient

received the medication at 9:27 AM and 11:48

AM. Similarly, the patient was scheduled to

receive Baclofen 20 mg (a muscle relaxant

medication) at 1:30 PM. The eMAR on 03/30/20

showed that the patient received this medication

at 1:25 PM, and again at 1:41 PM.

FORM CMS-2567(02-99) Previous Versions Obsolete G1XU11Event ID: Facility ID: 013299 If continuation sheet Page 4 of 5

A. BUILDING ______________________

(X1) PROVIDER/SUPPLIER/CLIA

IDENTIFICATION NUMBER:

STATEMENT OF DEFICIENCIES

AND PLAN OF CORRECTION

(X3) DATE SURVEY

COMPLETED

PRINTED: 08/04/2020FORM APPROVED

(X2) MULTIPLE CONSTRUCTION

B. WING _____________________________

DEPARTMENT OF HEALTH AND HUMAN SERVICES

CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

504016 04/07/2020STREET ADDRESS, CITY, STATE, ZIP CODENAME OF PROVIDER OR SUPPLIER

3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL

TACOMA, WA 98405

PROVIDER'S PLAN OF CORRECTION

(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)

(X5)

COMPLETION

DATE

ID

PREFIX

TAG

(X4) ID

PREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES

(EACH DEFICIENCY MUST BE PRECEDED BY FULL

REGULATORY OR LSC IDENTIFYING INFORMATION)

A 405 Continued From page 4 A 405

b. Patient #303 was to receive Sertraline 200 mg

(an antidepressant medication) daily at 12:00 PM.

The eMAR on 03/27/20 showed the patient

received the medication at 12:03 PM and 12:05

PM.

3. On 04/02/20 between 11:00 AM and 3:00 PM,

Investigator #3 interviewed the CNO (Staff #301)

and the Pharmacist in Charge (PIC) (Staff #303)

about the multiple documented entries identified

in the eMARs of Patient #302 and #303 for

medications administered around a scheduled

time. The PIC (Staff #303) provided

documentation from the Pyxis machine

(automated dispensing system) which showed

that the nurse retrieved the selected medications

only once from the Pyxis during those time

periods. The investigator asked how the duplicate

entries in the eMAR occurred. The CNO stated

that the issue appears to be a staff

training/knowledge problem with the use of the

medication administration barcoding system.

FORM CMS-2567(02-99) Previous Versions Obsolete G1XU11Event ID: Facility ID: 013299 If continuation sheet Page 5 of 5

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STATE OF WASHINGTON

DEPARTMENT OF HEALTHPO Box 47874 • Olympia, Washington 98504-7874

May 8, 2020

Ms. Pamela Shotts, RNDirector of QualityWellfound Behavioral Health Hospital3402 South 19th StreetTacoma, Washington 98405

Re: Complaint #98867/2020-5203

Dear Ms. Shotts,

Investigators from the Washington State Department of Health conducted a Statehospital licensing and Medicare hospital complaint investigation at Wellfound BehavioralHealth Hospital on April 1-3, 2020 and April 7, 2020. Hospital staff members developeda plan of correction to correct deficiencies cited during this investigation. This plan ofcorrection was approved on May 8,2020.

A Progress Report is due on or before July 6, 2020 when all deficiencies have beencorrected and monitoring for correction effectiveness has been completed. TheProgress Report must address all items listed in the plan of correction, including theWAC reference numbers and letters, the actual correction completion dates, and theresults of the monitoring processes identified in the Plan of Correction to verify thecorrections have been effective. A sample progress report has been enclosed forreference.

Please send a scanned copy of this progress report to me at the following emailaddress:

paul.kondrat@doh.wa.gov

Please contact me if you have any questions. I may be reached at (360)790 - 7365. Iam also available by email.

Sincerely,

:<^^jsrPaul KondratInvestigation Team Leader