^y^ , ' i ,'77^
15
^ ^ 1 I^^L) . . .,^ |^ /n i ^,fc(^. i-\^y^ , ' i ",'77^ <u^ ^ IAW i n ^A'CL sk//^^ "' ^ . I'. (. V^NNTED:C 'FORMAPPRW ^n A' 07/02/2 FORMAPPRO' State of Washington STATEME?'OF PERCIENCIES AND PLAN OF CORRECTION (Xl > PROVIOER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 013239 (XZ) MULTIPLE CONSTRUCTION Y A. BUILDING:. * , '"- • -../ '' i ] ~- 8 WING PWQATESUnVEY COMPLETED \.} • ±.L ^oe/03^020 ~7~7 r~~T NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CffY. STATE. »P CODE 3402 S 19TH ST WELLFOUND BEHAVIORAL HEALTH HOSPITAL mCOMA'.WA' 98406 (X4)tD PREFIX TAG L 000; L 315; SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IOEHTIFYING INFORMATION) INITIAL COMMBNTS STATE COMPLAINT INVESTIGATION The Washington State Department of Health (DOH) in accordance with Washington Administrative Code (WAG), Chapter 246-322 Private Psychialric and Alcohoiism Hospital, conducted this complaint investigation. Onsite dates: 06/02/20-06/03/20 Case number: 2020-7271 Intake number 100825 The investigation was conducted by: Investigator #5 Investigator #6 There were violations found pertinent to these complaints. 322-035.1C POLICIES.TREATMENT WAC 246-322-035 Policies and Procedures. (1) The licensee shall develop and implement the following written policies and procedures consistent with this chapter and services provided: (c) providing or arranging for the care and ID PREFIX TAG LOGO L315 PROVIDER'S PLAM OF CORRECTION {EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY] 1. A written PLAN OF CORRECTION Is required for each deficiency listed on (he Statement of Deficiencies. 2. EACH plan of correction statement must include the following: The regulation number and/or the tag number; HOW the deficiency will be corrected; WHO is responsible for making the cofrection; WHAT wilt be done to prevent reoccurrence and how you will monitor for continued compliance; and WHEN the correction will be completed. 3. Your PLANS OF CORRECTION must be returned within 10 calendar days from the date you receive the emailed Statement of Deficiencies. Your Plans of Correction must be emailed by 07/12/20. 4. Return the ORIGINAL REPORT via email with the required signatures. (X6) COMPLETE DATE I Stata Form 2567 LABORATORY DIRECTOR'S OR PROVIDER/SUPPL1ER REPRESENTATIVE'S SIGNATURE ilRECTOffS OR PROVIDER/SUPPL1ER REPRESENTATIVE'S S1G VA^TU- C\ ^.kZTC TITLE STATE FORM ^ £^> Pt6) DATE 7- /z-^i^ URUOH If continuation shoal lot?
Transcript of ^y^ , ' i ,'77^
^ ^ 1 I^^L) . . .,^ |^ /n i ^,fc(^.i-\^y^ , ' i ",'77^ <u^ ^ IAW i n ^A'CL
sk//^^ "' ^ . I'. (. V^NNTED:C'FORMAPPRW^n A'
07/02/2FORMAPPRO'
State of WashingtonSTATEME?'OF PERCIENCIESAND PLAN OF CORRECTION
(Xl > PROVIOER/SUPPLIER/CLIAIDENTIFICATION NUMBER:
013239
(XZ) MULTIPLE CONSTRUCTION Y
A. BUILDING:. * , '"- •
-../ '' i ] ~-
8 WING
PWQATESUnVEYCOMPLETED
\.} •
±.L^oe/03^020~7~7 r~~T
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CffY. STATE. »P CODE
3402 S 19TH STWELLFOUND BEHAVIORAL HEALTH HOSPITAL mCOMA'.WA' 98406
(X4)tDPREFIX
TAG
L 000;
L 315;
SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IOEHTIFYING INFORMATION)
INITIAL COMMBNTS
STATE COMPLAINT INVESTIGATION
The Washington State Department of Health(DOH) in accordance with WashingtonAdministrative Code (WAG), Chapter 246-322Private Psychialric and Alcohoiism Hospital,conducted this complaint investigation.
Onsite dates: 06/02/20-06/03/20
Case number: 2020-7271
Intake number 100825
The investigation was conducted by:
Investigator #5Investigator #6
There were violations found pertinent to thesecomplaints.
322-035.1C POLICIES.TREATMENT
WAC 246-322-035 Policies andProcedures. (1) The licensee shall
develop and implement the followingwritten policies and proceduresconsistent with this chapter andservices provided: (c) providingor arranging for the care and
IDPREFIX
TAG
LOGO
L315
PROVIDER'S PLAM OF CORRECTION{EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY]
1. A written PLAN OF CORRECTION Isrequired for each deficiency listed on (heStatement of Deficiencies.
2. EACH plan of correction statementmust include the following:
The regulation number and/or the tagnumber;
HOW the deficiency will be corrected;
WHO is responsible for making thecofrection;
WHAT wilt be done to preventreoccurrence and how you will monitor for
continued compliance; and
WHEN the correction will be completed.
3. Your PLANS OF CORRECTION mustbe returned within 10 calendar days fromthe date you receive the emailedStatement of Deficiencies. Your Plans ofCorrection must be emailed by 07/12/20.
4. Return the ORIGINAL REPORT viaemail with the required signatures.
(X6)COMPLETE
DATE
I
Stata Form 2567LABORATORY DIRECTOR'S OR PROVIDER/SUPPL1ER REPRESENTATIVE'S SIGNATUREilRECTOffS OR PROVIDER/SUPPL1ER REPRESENTATIVE'S S1G
VA^TU- C\ ^.kZTCTITLE
STATE FORM^ £^>
Pt6) DATE
7- /z-^i^URUOH If continuation shoal lot?
PRINTED: 07/02/2020FORM APPROVED
State of WashingtonSTATEMEm OF OERCIENCIESAND PLAN OF CORRECTtOM
(X1) PROViDER/SUPPLIER/CUAIDENTtFICATtON NUMBER:
013299
(X2) MULTIPLE CONSTRUCTION
A. BUILDING:.
8. WING.
(X3) DATE SURVEYCOMPLETED
c06/03/2020
NAME OF PROVIDER OR SUPPLIER
WELLFOUND BEHAVIORAL HEALTH HOSPITAL
STREET ADDRESS, Cin'. STATE, ZfP CODE
3402S19THSTTACOMA, WA 98405
(X4»IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES(EACH OEFtCIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDEI^TIFYtNG INFORf/ATION)
IDPREFIX
TAG
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATEOEFJCIEMCY)
(XS)COMPLETE
DATE
L315 Continued From page 1
treatment of patients;This Washington Administrative Code is not metas evidenced by:
Based on interview, document review, and review
of hospital policy and procedures, the hospitalfailed to implement policies for assessing andreassessing patients who are victims of physicalassault while hospitalized for 1 of 2 assaultivepatient incidents reviewed.
Failure lo assess and reassess patients followinga physical assault can lead to palient harm anddeath.
Findings included:
1. Document review of (he hospital's policy andprocedure titled, "Patient Assessment andReassessment-lnpatient." policy number7808121, revised 10/19 showed that nursing staffwill document a physical and psychiatricassessment ever/ shift and as needed andadditional information for an "event" will bedocumented in the Nursing Note section of thepatient medical record.
Document review of the hospital's policy andprocedure titled, "Record Completion, Retention,
Destruction," policy number 7804408, revised10/19 showed thai the purpose of the medicalrecord is to serve as a basis for planning patientcare, for continuity of care, and to furnish
documentary evidence of the course of thepatient's medical evaluation, tfeatment, andchange in condition during the hospital stay. Themedica! record must include any findings ofassessments and reassessments, any diagnosis,or conditions established during the patient's
L315
Slate Form 2567STATE FORM URU011 H coniinualion sheet 2 of 7
PRINTED: 07/02/2020FORM APPROVED
Stale of Ws^hinatonSTATEMENT OF ORFICIENCIESAND PLAN OF CORRECTION
(Xl) PROVIOER/SUPPUER/CLtAIDENTIFiCATIOH NUMBER:
013299
(X2) MULTIPLE CONSTRUCTION
A, BUILDING:
B. WING
(X3» DATE SURVEYCOMPLETED
c06/03/2020
NAME OF PROViDER OR SUPPLIER STREET ADDRESS. Cin', STATE. ZIP CODE
3402 SWELLFOUND BEHAVIORAL HEALTH HOSPITAL ^^ ^ ^
(X4) IDPREFIX
TAG
L31S|
L340!
SUMMARY STATEMENT OF OEFIOENCIES(EACH DEFICIENCy MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTtFYING INFORf/ATION)
Continued From page 2
course of care, Ireatment, and services, and any
observations relevant to care. treatment and
services.
2. On 06/02/20 from 9:00 AM until 3:00 PM duringinterviews with hospital staff. Staff #502, Staff#503, Staff #504. Staff #505, Staff #506, andStaff #507stated that Patient #501 had physicallyassaulted Patient #502.
3. On 06/03/20 at 4:10 PM, Investigalor #5 and(he Chief Nursing Officer (Staff #501) reviewedthe medical records for Patient #501 and #502.The review showed the following:
a. On 05/W20 at 7:20 AM, a nursing note slatedthat while trying to move Patient #501 to aseclusion room, Patient #501 "attacked anotherpatient, dragging the patient to the ground."
b. On 05/14/20 at 1:13 PM, a provider note slatedthat Patient #501 had "attacked another patient,dragging that patient to the ground."
c. During review of the medical record for Patient#502, Investigator ff5 found no evidence that staffcompleted or documented an assessment or
reassessment of the patient for injury or changein condition after the assault.
4. At the time of the observation. Staff #501confirmed the finding and stated that staff shouldhave documented an assessment of the patientafter the incident.
322.035.1 H PROCEDURES-BEHAVIOR
i/VAC, 246-322-035 Policies and
[0PREFIX
TAG
L 315
L 340
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE
CROSS.REFEREMCED TO THE APPROPRIATEDEFiCtENCY^
(MlCOMPLETE
KATE
State Form 2567STATE FORM URU011 t( continuation sheet 3 of 7
PRINTED: 07/02/2020FORM APPROVED
State of WashingtonSTATEMENT OF OCFfOENCSESAND PLAN OF CORRECTiON
(X1) PROVIOER/SUPPLIER/CUAIDENTIFICAT!OM NUMBER:
01329S
(X2) MULTIPLE CONSTRUCTiON
A. BUILDING:
B. WING.
(X3) DATE SURVEYCOMPLETED
c06/03/2020
NAME OF PROVIDER OR SUPPLIER
WELLFOUND BEHAVIORAL HEALTH HOSPITAL
STREETADDRESS. CrTY. STATE. ZIP CODE
3402S19THSTTACOMA, WA 98405
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFfClENGY MUST BE PRECEDED BY FULLREGULATORY OR LSC JOENTIFYING INf-'ORMATiON)
10PREFIX
TAG
PROVIDER'S PLW OF CORRECTION(EACH CORRECTIVE ACTION SHOULD 6£
CROSS-FtEFEREHCEO TO THE APPROPRIATEDEFICIENCY)
(US)COMPLETE
DATE
L 340 Continued From page 3
Procedures. (1) The licensee shalldevelop and implement the followingwritten policies and proceduresconsistent with this chapter andservices provided: (h) Managingassauitive, self-destructive. or
out-of-control behavior, including:
(i) immediate actions and conduct;(Ei) Use of seclusion and restrainisconsislent with WAG 246-322-180 andother applicable state standards;(ill) Documenting En the clinicalrecord;This Washington Administrative Code is nol metas evidenced by:Based on nterview, document review. and reuiew
of hospital policy and procedures showed that thehospital failed to implement its Code Gray Policy.
Failure to implement documentation andreporting of the hospital's Code Gray Policy limitsthe hospitals ability to collect accurate dala,identify trends and patterns, and implementprocess improvement.
Findings included:
1. Document review of the hospital's policy tilled,"Code Gray Policy," policy number 7808170,revised 10/19 showed the following:
"A Debrief/Huddie fonn will be completed in atimely manner by Ihe Code Gray team and wil) besubmitted to the department supervisor. It will beused weekly during Harm Huddle Discussions,during Safely Committee meetings, and/or forsupplemental injury investigations.
•The Debrief/Huddle form may be reviewed byregulatory agencies.
L 340
Slate Form 2567STATE FORM URU011 H continuation sheet 4 of 7
PRINTED; 07/02/2020FORM APPROVED
State of WafihjofllpnSTATEMENT OF OEFlCIENCiESAND PLAM OF CORRECTION
(Xi) PROVtOKR/SUPPUER/CUAIDENTIFfCATiON NUMBER:
013299
(X2) MULTIPLE: CONSTRUCTION
A. BUILDING:,
B.WNG.
(X3) DATE SURVEYCOMPLtHED
c06/03/2020
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CIPi'. STATE. Z:IP CODE
WELLFOUND BEHAVIORAL HEALTH HOSPITAL ^MA^M-OS
(X4) IDPREFIX
TAG
L 340
SUMMARY STATEMENT OF OEFlCIENCtES(EACH DEFICIENCY MUST OE PRECEDED BY FULtREGULATORY OR LSC IDENTIFYING INFORMATtON)
Continued From page 4
-The team leader will complete an IncidentReport.
-Security will complete a Security Case Report,which will include the escalation level, thebehavior exhibited, and the staffs response to theincident.
•If it is a patient offense, the patient's medicalrecord wili be documented with the appropriateinformation related to the incident, by the medicalpersonnel.
2. On 06/03/20 at 3:30 PM. Investigator U5 andthe Chief Nursing Officer reviewed the hospital'sincident Report Log. At this time, Surveyor #5asked to review the Code Gray Debrief for theevent involving Patient #501 on 05/14/20. Theincident included an assault on another patient.Investigator #5 was not provided with the debriefform for this incident or any others.
During the investigation process, the foHowingwas discovered:
a. Security did not compfote Code Gray CaseReports.
b. Code Gray data was not collected or analyzed.
c. Code Gray Debrief and Huddle sheets werenot provided to or reviewed by the Hospital'sSafety Committee.
3. At the time of the finding, the Staff #501consulted with the Security and EnvironmentalServices team and verified the finding. She staledthat because the volume of Code Grays called inthe hospital, Ihis would not be a feasible policy to
10PREFIX
TAG
L 340
PROVtDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO TH£ APPROPRIATEDEFICIENCY)
(XS)COMPLETE
DATE
State Form 2567STATE FORM URUOH If continuation ahcot 5&(7
PRINTED: 07/02/2020FORM APPROVED
State of WashincitonSTATEMENT OF DEFtCtENCiESAND PLAN OF CORRECTION
(Xl) PROVIDER/SUPPLIER/CUAIDEHTtRCATION NUMBER.
0132S9
(X2) MULTiPLR CONSTRUCTION
A. BUILDING;
8. WING
(X3) DATE SURVEYCOMPLETED .
c06/03/2020
NAME OF PROViDER OR SUPPLIER STREET AODRE3S, CjTY, STATE. ZiP CODE
3402 S 19THSTWELLFOUND BEHAVIORAL HEALTH HOSPITAL
TACOMA, WA 98405
(X^)IDPREfW
TAG
L 340 ;
L 355;
SUMMARY STATEMENT OF DEFfCIENCIES(EACH DEFICIENCY MUST BE PRECEDED SY FULLREGUUffORY OR LSC IDEN'TIFYIHG INFORMATfON)
Continued From page 5
implement.
322-035.1K POLICIES-STAFF ACTIONS
WAC 246-322-035 Policies andProcedures. (1) The licensee shalldevelop and implement the followingwritten policies and proceduresconsistent with this chapter andservices provided: (k) Staff actionsupon: (i) Patient elopement; (ii) Aserious change En a patient'scondition, and immediately notifyingfamily according to chapters 71.05 and71.34 RCW; (Jii) Accidents orincidents potential!/ harmful orinjurious to patients, anddocumentation in the clinical record;(iv) Patient death;
! This Washington Administrative Code is not metas evidenced by:
Based on inten/iew, document review. and review
of hospital policy and procedure, the hospitalfailed to ensure that staff reported patient safetyevents for 1 of 2 patient safely events reviewed(Patient #502).
Failure to report and investigate patient safetyincidents limits the hospital's ability to analyze
) accurate data. implement performance
improvement activities, and can result in anunsafe heaithcare environment.
Findings included:
1 Document review of the hospital's policy andprocedure tilled, "Critical Event Management and
IDPREFIX
TAG
L 340
L 355
PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFEReNCEO TO THE APPROPRIATEOEFtCSEHCY)
(X5)COMPLETE
DATE
Slato Form 2567STATE FORM URU011 (f continuation ahccl 6 of 7
PRINTED: 07/02/2020FORM APPROVED
State of WasiijngtonSTATEMENT-OF DEFICIENCIESAND PLAN.SOF CORRECTION
(X1) PROVIOER/SUPPUER/aiAIDENTIFICATIOM NUMBER:
0132S9
(X2) MULTIPLE CONSTRUCTiON
A. BUILDING:.
B. WING.
(X3) DATE SURVEYCOMPLETED
c06/03/2020
NAME OF PROVIDER OR SUPPUER
WELLFOUND BEHAVIORAL HEALTH HOSPITAL
STREET ADDRESS. CITf, STATE. ZIP CODE
3402S-t9THST
TACOMA, WA 98405
(X4) IDPREFIX
TAG
SUMMARY STATEMENT OF DEFICIENCIES(EACH OEFIOENCY MUST BE PRECEDED BY FULLREGULATORY OR ISO IDENTIFYING INFORMATION)
IDPREFIX
TAG
PROViDER'S PLAN OF CORRECTION(EACH CORftECTiVEACTiON SHOULD OE
CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)
(X5)COMPLETE
DATE
L 3551 Continued From page 6
Disclosure," policy number 7808463, revised10/19 showed that critical events or occurrencesare defined as events causing, or having thepotential to cause serious patient harm. If anevent is discovered staff will take actions tostabilize the patient, correct the situation andprevent or minimize injury, noiify their supervisoras soon as possible, and Emliafe a paper incidentreporting form. The form should be completedwithin 12 hours ofdiscoverincj (he event.
Document review of the hospital's policy andprocedure titled, "Incident Reporting Guidelines(for Unusual Occurrence and Critical Events,"policy number 7808523, revised 10/19. showedthat incident reports are created for any event oroccurrence that is unusual or inconsistent with
routine care of a patient or routine safetyoperations of the organization. Reports are
completed by the person who discovers,witnesses, or identifies the event and should becompleted within 12 hours of discovering theoccurrence or event,
2. On 06/03/20 at 3:30 PM, Invesfigator #5 andthe Chief Nursing Officer (Staff #501) reviewedthe hospital's incident report log. Surveyor #5found no evidence that staff completed anincident report for the assault of Patient #502perpetrated by Patient #501 on 05/14/20.
; 3. At the time of the finding, Staff #501 verifiedthat staff had not reported or completed anincident report for assaultive event.
L 355
State Form 2567STATE FORM URU011 ifcontirwotlonaheot 7 of 7
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STATE OF WASHINGTON
DEPARTMENT OF HEALTHPO Box 47874 • Olympia, Washington 98504-7874
September 11,2020
Matt CrockettChief Executive OfficerWellfound Behavioral Health Hospital3402 South 19th StreetTacoma, WA 98405
Dear Mr. Crockett,
Surveyors from the Washington State Department of Health conducted a state hospital complaintinvestigation at Wellfound Behavioral Health Hospital on 06/02/20-06/03/20. Hospital staffmembers developed a plan of correction to correct deficiencies cited during this survey. Thisplan of correction was approved on 07/29/20.
Hospital staff members sent a Progress Report dated 09/02/20 that indicates all deficiencies havebeen corrected. The Department of Health accepts Wellfound Behavioral Health Hospital'sattestation to be in compliance with Chapter 246-322 WAC.
The team sincerely appreciates your cooperation and hard work during the survey process andlooks forward to working with you again in the future.
Sincerely,
'^/^
Kimberly Metz DNP, RNSurvey Team LeaderDepartment of Health HSQAPO Box 47874Olympla, WA 98504-7874
