PRINTED: 05/29/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 500014 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 04/08/2019 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1321 COLBY AVENUE PROVIDENCE REGIONAL MEDICAL CENTER EVERETT (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 000 INITIAL COMMENTS EVERETT, WA 98201 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 000 MEDICARE COMPLAINT INVESTIGATION The Washington State Department of Health (DOH) in accordance with Medicare Conditions of Participation for Hospitals set forth in 42 CFR 482, conducted this health and safety investigation. Onsite dates: : 03/25/19, 03/26/19, 03/27/19 and 03/28/19. Additional information was obtained on 04/08/19. Intake number: 88008, 86225 and 86226 The investigation was conducted by: Surveyor #19812 A 144 PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) A 144 The patient has the right to receive care in a safe setting. This STANDARD is not met as evidenced by: Based on interview, record review and review of policy and procedure, the hospital failed to ensure that patients received care in a safe setting by not assuring a safe hospital-to-hospital transfer for 1 of 11 patients whose records were reviewed (Patient #1). Failure to ensure a safe hospital-to-hospital transfer places patients at risk of harm due to placement in a hospital that cannot meet their health care needs. Findings included: 1. On 03/25/19, at approximately 3:00 PM, the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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 Event ID: 9EU711 Facility ID: 000058 If continuation sheet Page 1 of 3 PRINTED: 05/29/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 500014 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 04/08/2019 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1321 COLBY AVENUE PROVIDENCE REGIONAL MEDICAL CENTER EVERETT (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 1 Manager of Patient Safety and Risk Management (Staff #2) stated that the hospital followed EMTALA policy, and followed the "Emergency Department Standards of Care" guidelines, when transferring/discharging patients from the ED to other facilities. EVERETT, WA 98201 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 144 2. Record review of the hospital's policy and procedure titled, "EMTALA: General Guidelines to Examination, Treatment and Transfer of Patient," Policy #5922818, reviewed 02/19, showed that the receiving facility must have available space and personnel for the care of the patient, and must agree to accept the transfer of the patient. a. Record review of the "Emergency Department Standards of Care" guidelines, policy #5871821, last reviewed 01/19, showed that on page 3 of 5 staff were directed to complete documentation per the EMTALA guidelines. The policy stated under #4 that report was to be communicated to the accepting RN and LIP [licensed independent practitioner] by the ED LIP, ED RN and the ED Crisis Counselor as indicated. 3. Review of Patient #1's medical record showed: a. Patient #1 was transferred from the hospital's ED to a behavioral health hospital on 04/03/18, 04/24/18, 05/28/18, 06/19/18 and 06/28/18. b. There was no documentation that showed that the receiving hospital had agreed to accept transfer of the patient or provide the appropriate and necessary medical care for Patient #1 on 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9EU711 Facility ID: 000058 If continuation sheet Page 2 of 3 PRINTED: 05/29/2019 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: 500014 OMB NO. 0938-0391 (X2) MULTIPLE CONSTRUCTION C 04/08/2019 B. WING _____________________________ NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 1321 COLBY AVENUE PROVIDENCE REGIONAL MEDICAL CENTER EVERETT (X4) ID PREFIX TAG (X3) DATE SURVEY COMPLETED A. BUILDING ______________________ SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) A 144 Continued From page 2 of 5 transfer dates (04/03/18, 04/24/18, 05/28/18, and 06/19/18). EVERETT, WA 98201 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG (X5) COMPLETION DATE A 144 c. There was no documentation that showed that the sending ED RN had communicated report to the RN at the receiving hospital on 1 of the 5 dates the patient was transferred (04/03/18). d. There was no documentation that showed that there had been physician/LIP to physician/LIP communication on 4 of the 5 dates the patient was transferred (04/03/18, 04/24/18, 05/28/18 and 06/19/18). 4. The above findings were confirmed with the Director of Compliance and Accreditation (Staff #1) and the Manager of Patient Safety and Risk Management (Staff #2) on 03/28/19 at 4:45 PM. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9EU711 Facility ID: 000058 If continuation sheet Page 3 of 3