aocs state of Washington STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI ) PROVIDEFySUPPLIER/CLIA IDENTIFICATION NUMBER: PRINTED: 01 /22/201 9 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SUR\/EY COMPLETED A. BUILDING: c B. WING 01 31 34 NAME OF PROVIDER OR SUPPLIER S M O K E Y P O IN T B E H A VIO R A L H O S P ITA L 08/22/201 8 STREET ADDRESS, CITY, STATE, ZIP CODE 39SS 1 S6TH S T N E M A R Y S V IL L E , W A 9 8 2 7 1 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG LOGO INITIAL COMMENTS (X5) COMPLETE DATE LOGO STATE COMPLAINT INVESTIGATION 1 . A written PLAN OF CORRECTION is required for each deficiency listed on the 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 correction; * WHAT will be done to prevent reoccurrence and how you will monitor for continued compliance; and ' WHEN the correction will be completed. 3. Your PLAN OF CORRECTION must be returned within 1 0 calendar days from the date you receive the Statement of Deficiencies. PLAN OF CORRECTION • DUE: SEPTEMBER 1 0, 201 8 4. The Administrator or Representative's signature is required on the first page of the original. 5. Return the original report with the required signatures. The Washington State Department of Health (DOM) in accordance with Washington Administrative Code (WAC), Chapter 246-322 Private Psychiatric and Alcoholism Hospitals, conducted this health and safety investigation. Service categories; State Private Psychiatric and Alcoholism Hospitals Onsite dates: 08/22/1 6 Examination number: 201 8-1 1 389 Intake number: 83582 The investigation was conducted by: Surveyor #27347 There were violations found pertinent to this complaint. L305 322-035.1 A POLICIES-ADMIT CRITERIA PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG L3G5 9/5 /1 8 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: (a) Criteria for admitting and retaining patients; This Washington Administrative Code is not met as evidenced by: Based on interview, review of hospital documents and review of acute care hospital documents the hospital failed to implement their policy to transfer State Form 2557 TITLE LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE STATE FORM U 0 E 81 1 (X6) DATE If continuation sheet 1 of 7 SR_2019-01232019 SOD'S PAGE 71 aoa-u^,'g ID PREFIX TAG (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) L505 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 L505 On 06/23/201 8 hospital psychiatric consultation notes stated "Asked to evaluate would patient benefit for nursing home care". "Patient elderly female who isn't getting out of bed to urinate", "fecal incontinence". "Poor po (oral) intake", "If change in level of consciouness may send to ER (emergency room) for evaluation". On 06/29/201 8 hospital psychiatric consultation notes stated "Patient lying in bed and no response to questions and appears to be confused. Has not been eating or drinking for at least 4 days, refuses medications. Her physical conditions are deteriorating. Emergency meeting held with medical director, chief op erating officer and patients daughter. Ail agreed to send patient to emergency room and patient needs to be admitted to medical floor for treatment". On 06/29/201 8 the acute care hospital admitted the patient to the medical floor. The patie nt was found to be "hypotensive with systolic blood pressure in the 80's, hypoglycemia, a humerus fracture, and schizoaffective disorder. After receving IV fluids the patient was able to answer questions asked by the hospital staff and relayed falling in the facility last week and "broke their arm". 3. There was no documentation found to indicate the medical doctor was involved in reassessing the patient's medical cx)ndition during their hospital stay, after emergency room visits or in talking with the emergency room staff about the patient's condition. 4. On 08/22/201 8 at 1 1 :00 AM Staff A was interviewed. Staff A stated that patients needed to be able to eat and drink by themseif and if they S tate Form 2567 STATE FO RM U 0E81 1 If continuation sheet 6 of 7 SR_2019-01232019 SOD'S PAGE 76 PRINTED: 01 /22/201 9 FORM APPROVED State of V\feshinqton STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1 > PROV IDER/SUPPLIER/CLIA IDENTIFICATION NUMBER; S M O K E Y P O IN T B E H A VIO R A L H O S P IT A L A. BUILDING: (X3) DATE SURVEY COMPLETED c B.WIN G 01 31 34 NAME OF PROVIDER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION 08/22/201 8 STREET ADDRESS, CITY, STATE, ZIP CODE 39 55 1 56TH S T N E M A R Y S V IL L E , W A 9 8 2 7 1 SUMMARY STATEMENT OF DEFICIENCIES" {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) ID PREFIX TAG L505 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 L505 were not able to do this they would need to be transferred to another care setting possibly a nursing home or acute care hospital. Staff A Stated the psychiatrist was the primary person to notified of patient changes. 5. On 08/22/201 8 at 1 1 :30 AM Staff B verified the above information. 6. On 8/22/201 8 at 1 2:00 PM Staff 0 stated the behavioral health hospital was looking at their admission criteria to ensure they did not take patients that were not able to adequately perform their own ADL's were not admitted to the facility. Staff 0 stated the psychiatrist would call the medical doctor If a consult or reassessment was needed. S tate Form 2567 STATE FO RM U 0 E 81 1 If continuation sheet 7 of 7 SR_2019-01232019 SOD'S PAGE 77