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:
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