PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 000 INITIAL COMMENTS

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 000

.
STATE LICENSING SURVEY

1 . A written PLAN OF CORRECTION is
required for each deficiency listed on the
Statement of Deficiencies.

The Washington State Department of Health
(DOH) in accordance with Washington
Administrative Code (WAC), Chapter 246-322
Private Psychiatric and Alcoholism Hospitals,
conducted this health and safety survey.

2. EACH plan of correction statement
must include the following:
The regulation number and/or the tag
number;

Onsite dates: 09/25/1 8 to 09/28/1 8

HOW the deficiency will be corrected;

Examination number: 201 8-787

WHO is responsible for making the
correction;

The survey was conducted by:
WHAT will be done to prevent
reoccurrence and how you will monitor for
continued compliance; and

Surveyor #2
Surveyor #3
The Washington Fire Protection Bureau
conducted the fire life safety inspection.

WHEN the correction will be completed.
3. Your PLANS OF CORRECTION must
be returned within 1 0 calendar days from
the date you receive the Statement of
Deficiencies. Your Plans of Correction
must be postmarked by October 22, 201 8.
4. Return the ORIGINAL REPORT with
the required signatures.

L 345 322-035.1 i POLICIES-PHARMACY

L 345

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: (i) Pharmacy
and medication services consistent
with WAC 246-322-21 0;
State Form 2567
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM

TITLE

6899

8IDV11

(X6) DATE

If continuation sheet 1 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 1

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 345 Continued From page 1

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 345

This Washington Administrative Code is not met
as evidenced by:
.
Based on record review, interview, and review of
hospital policies and procedures, the hospital
failed to ensure staff members perform and
document assessments prior to administering
medication ordered by a physician for 2 of 3
patient records reviewed (Patient #302, #303).
Failure to assess and follow medication protocols
puts patients at risk for delayed or inadequate
treatment and may result in patient harm.
Findings included:
1 . Document review of the hospital's policy titled,
"CIWA," policy number AR.C.21 0, last reviewed
09/1 8, showed that initiation of the Clinical
Institute Withdrawal Assessment (CIWA) protocol
set order must be ordered by a practitioner.
Nursing staff will follow the CIWA protocol upon
initiation by a provider.
2. On 09/26/1 8 at 1 2:50 PM, Surveyor #3
reviewed the medical record of three patients who
were placed on the CIWA protocol for alcohol
withdrawal during their hospitalization. The
review showed:
a. Patient #302 was admitted on 09/25/1 8 and
assessed on 09/26/1 8 at 6:00 AM with a total
CIWA score of 7 and was administered 1 mg of
lorazepam (an antianxiety medication) by mouth
as prescribed by the protocol.
-A second dose of lorazepam 1 mg was
administered on 09/26/1 8 at 9:00 AM; however,
no CIWA assessment was performed by the
nursing staff prior to the medication
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 2 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 2

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 345 Continued From page 2

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 345

administration. A CIWA assessment was
performed at 1 0:00 AM, which is one hour after
medication administration.
b. Patient #303 was admitted on 09/25/1 8 and
administered 0.5 mg of lorazepam by mouth on
09/26/1 8 at 9:00 PM. No CIWA assessment was
performed by the nursing staff prior to medication
administration. A CIWA assessment was
performed at 1 0:00 PM, which is one hour after
medication administration.
3. On 09/26/1 8 at 2:00 PM, Surveyor #3
interviewed the Nurse Manager (#301 ) about the
CIWA protocol. Staff #301 stated the CIWA
protocol is designed so that a CIWA assessment
score is obtained and then the corresponding
medication is administered based upon that
score. He confirmed the nursing staff had not
followed the protocol as prescribed by the
practitioner.
L 450 322-040.7 ADMIN-APPOINT STAFF

L 450

WAC 246-322-040 Governing Body and
Administration. The governing
body shall: (7) Appoint and
periodically reappoint the
professional staff;
This Washington Administrative Code is not met
as evidenced by:
.
Based on record review and interview, the
hospital failed to ensure that a physician assistant
had a documented Physician Assistant
Delegation Agreement.
Failure to ensure that physician assistants have
physician supervision places patients at risk for
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 3 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 3

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 450 Continued From page 3

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 450

inadequate care.
Reference: Revised Code of Washington (RCW)
1 8.71 A.040 (1 ) (2), (1 ) No physician assistant
practicing in this state shall be employed or
supervised by a physician or physician group
without the approval of the commission. (2) Prior
to commencing practice, a physician assistant
licensed in this state shall apply to the
commission for permission to be employed or
supervised by a physician or physician group.
The delegation agreement shall be jointly
submitted by the physician or physician group
and physician assistant. Administrative
procedures, administrative requirements, and
fees shall be established as provided in RCW
43.70.250 and 43.70.280. The delegation
agreement shall delineate the manner and extent
to which the physician assistant would practice
and be supervised. Whenever a physician
assistant is practicing in a manner inconsistent
with the approved delegation agreement, the
commission may take disciplinary action under
chapter 1 8.1 30 RCW.
Findings included:
1 . On 09/27/1 8 from 11 :30 AM to 1 2:30 PM,
Surveyor #2 reviewed medical staff credentialing
records. Record review of the medical staff
credentialing files for a physician assistant (Staff
#208) showed that the document, "Physician
Assistant Delegation Agreement and
Standardized Procedures Reference and
Guidelines," a required supervisory agreement,
was not on file and had not been submitted to the
Medical Commission.
2. On 09/27/1 8 at 3:1 5 PM, Surveyor #2
interviewed the Medical Staff Coordinator (Staff
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 4 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 4

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 450 Continued From page 4

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 450

#209) about the missing supervisory agreement
for Staff #208. The coordinator stated that she
was unable to find the required documents and
that it was not submitted to the commission. The
coordinator had the physician assistant and the
supervising physician (Staff #21 0) complete the
agreement after the credentialing review.
L 670 322-050.1 2G RECORDS-PERFORM EVALS

L 670

WAC 246-322-050 Staff. The licensee
shall: (1 2) Maintain a record on the
hospital premises for each staff
person, during employment and for two
years following termination of
employment, including, but not limited
to: (g) Annual performance
evaluations.
This Washington Administrative Code is not met
as evidenced by:
.
Based on document review, the hospital failed to
ensure that annual performance evaluations were
performed and retained for 5 of 9 staff members
reviewed (Staff #201 , #202, #203, #204, #205).
Failure to conduct annual performance
evaluations limits the hospital's ability to ensure
that staff members are satisfactorily performing
required job duties.
Findings included:
1 . Recrod review of the hospital policy titled,
"Performance Evaluations," policy number
EHB.P.200, reviewed 01 /1 8, showed that staff
should receive annual performance reviews.
2. On 09/27/1 8 from 1 0:00 AM to 11 :30 AM,
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 5 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 5

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L 670 Continued From page 5

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L 670

Surveyor #2 reviewed human resources records
for 9 staff members. Review of the annual
performance evaluations showed the following:
a. A registered nurse (Staff #201 ), hired in 11 /1 6,
did not have a completed annual performance
evaluation in his personnel file.
b. A mental health technician (Staff #202) had her
last performance evaluation conducted on
05/11 /1 7.
c. A mental health technician (Staff #203) had her
last performance evaluation conducted in 06/1 7.
d. A chemical dependency professional (Staff
#204) had her last performance evaluation
conducted in 07/1 7.
e. A mental health technician (Staff #205) had her
last performance evaluation conducted in 06/1 7.
3. Surveyor #2 reviewed personnel files with the
Human Resources Director (Staff #204). During
the review, the director confirmed that the
identified staff members did not receive recent
annual performance evaluations.
L11 65 322-1 80.2 EMERGENCY SUPPLIES

L11 65

WAC 246-322-1 80 Patient Safety and
Seclusion Care. (2) The licensee
shall provide adequate emergency
supplies and equipment, including
airways, bag resuscitators,
intravenous fluids, oxygen, sterile
supplies, and other equipment
identified in the policies and
procedures, easily accessible to
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 6 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 6

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L11 65 Continued From page 6

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L11 65

patient-care staff.
This Washington Administrative Code is not met
as evidenced by:
.
Based on observation, document review, and
interview, the hospital failed to have all the
required emergency supplies available for patient
care for 6 of 6 patient care units reviewed.
Failure to have the required emergency supplies
available risks delayed patient care and
treatment.
Findings included:
1 . Document review of the hospital's policy titled,
"Emergency Cart," policy number PC.C.11 0, last
reviewed 01 /1 8, showed that "all emergency carts
will be stocked according to WAC 246-322-1 80
standards". Emergency carts will be secured and
available on all patient care units at all times for
emergency use.
Document review of the hospital's daily log for
emergency cart inventory checks showed a list of
the cart's contents by drawer. The inventory list
did not include intravenous fluids and associated
items to initiate intravenous therapy as part of its
contents.
2. On 09/25/1 8 at 9:00 AM during a tour of the
2-West Adult Psychiatric Unit, Surveyor #3
inspected their emergency cart. The surveyor
observed there were no intravenous fluids and
associated items to initiate intravenous therapy in
the cart.
3. On 09/25/1 8 at 9:30 AM, Surveyor #3
interviewed the Nurse Manager (Staff #301 )
about the 2-West emergency cart. Staff #301
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 7 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 7

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L11 65 Continued From page 7

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L11 65

stated that none of the hospital's emergency carts
contained intravenous fluids as part of their
inventory stockage list. He indicated the hospital
does not perform intravenous therapy as part of
its service.
L1 265 322-200.3F RECORDS-OBSERVATIONS

L1 265

WAC 246-322-200 Clinical Records. (3)
The licensee shall ensure prompt entry
and filing of the following data into
the clinical record for each period a
patient receives inpatient or
outpatient services: (f) Significant
observations and events in the
patient's clinical treatment;
This Washington Administrative Code is not met
as evidenced by:
.
Based on record review and review of hospital
policies and procedures, the hospital failed to
document significant medical emergencies in the
clinical treatment for 1 of 2 patient records
reviewed (Patient #301 ).
Failure to document a patient's cardiac arrest
decreases the quality of the information the
hospital can provide for ongoing treatment of the
patient and hinders the hospital's ability to
evaluate the effectiveness of their emergency
response.
Findings included:
1 . Document review of the hospital's policy and
procedure titled, "Code Blue," policy number
PC.C.1 00, last reviewed 01 /1 8, showed that the
code blue event will be documented on the Code
Blue Record and placed in the medical record
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 8 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 8

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L1 265 Continued From page 8

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L1 265

when completed. The Code Blue will be
evaluated through completion of the Code Blue
Evaluation form by the Registered Nurse.
Document review of the hospital's policy and
procedure titled, "Code Blue Response - Medical
Emergency / Cardiac Arrest," policy number
EM-024, last revised 01 /1 8, showed that if a
person receiving cardiopulmonary resuscitation
(CPR) is a patient, staff will document in the
medical record several items. These items
include: assessment of the condition, time,
placed found, what was done by staff, patient's
response to what was done, when patient left
facility, and where he/she was transferred, and in
what condition the patient was in when they left
the facility.
Document review of the hospital's policy and
procedure titled, "Documentation Protocols,"
policy number PC.L.300, last reviewed 01 /1 8,
showed that staff are to document accurately the
services provided.
2. Record review of Patient #301 revealed the
following:
Patient #301 was a 52-year old woman admitted
on 07/07/1 8 for acute psychosis with a significant
medical history for morbid obesity, diabetes, and
hypertension. On 07/1 6/1 8, the patient was found
unresponsive in her room during routine patient
checks. A code blue was initiated, and eventually
death was declared.
No Code Blue Form documenting the staff's
response to the patient's cardiac arrest could be
located in the patient's medical record. No
nursing or physician note describing the event
could be found. Additionally, no Code Blue
State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 9 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 9

 PRINTED: 02/04/201 9
FORM APPROVED

State of Washington
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION

(X1 ) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:

CASCADE BEHAVIORAL HOSPITAL

A. BUILDING: ______________________

09/28/201 8

STREET ADDRESS, CITY, STATE, ZIP CODE

1 2844 MILITARY ROAD SOUTH
TUKWILA, WA 981 68

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)

(X4) ID
PREFIX
TAG

(X3) DATE SURVEY
COMPLETED

B. WING _____________________________

604291 97
NAME OF PROVIDER OR SUPPLIER

(X2) MULTIPLE CONSTRUCTION

L1 265 Continued From page 9

PROVIDER'S PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD BE
CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

ID
PREFIX
TAG

(X5)
COMPLETE
DATE

L1 265

Evaluation form could be located for the cardiac
arrest event.
3. On 09/27/1 8 at 3:00 PM, Surveyor #3
interviewed the Director of Risk & Quality
Management (Staff #302) about Patient #301 's
cardiac arrest and associated documentation.
Staff #302 confirmed the missing documentation
and the expectation that staff document the
medical emergency events in the patient's
medical record.

State Form 2567
STATE FORM

6899

8IDV11

If continuation sheet 1 0 of 1 0

X2018-787 CASCADE BEHAVORIAL HOSPITAL PAGE 10

 X2018 787 Cascade Behavioral Hospital_pdf-r.pdf redacted on: 2/5/2019 08:27
Redaction Summary ( 0 redactions )
0 Privilege / Exemption reason used:

Redacted pages:

Page 1