Printed: 03i231201 7

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8c MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF (x1) PROVIDERISUPPLIERICLIA CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION EDENTIFICATION NUMBER: A. BUILDING COMPLETED

504011 e. WING 03i10i2017
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY. STATE. CODE
CASCADE BEHAVIORAL HOSPITAL 12344 MILITARY ROAD SOUTH
TUKWILA, WA 98168
(M) ID SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION 06)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED ev FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE 
TAG OR LSC TAG TO THE APPROPRIATE DATE

000} INITIAL COMMENTS 000}

MEDICARE HOSPITAL COMPLAINT SURVEY
FOLLOW-UP VISIT

An on-Site foiiow-up visit was conducted on
March 7 -10,2017 by Paut Kondrat, RN, MN,
Elizabeth Gordon, RN, Joy Wiliiams,
RN, BSN, and Alex Giei, REHS, PHA.

The Fire Life Safety (FILS) follow-up Visit was
conducted on March 7, 2017 by Washington
State Patroi Deputy Fire Marshal Don West.

During the survey, surveyors aiso assessed
issues reiated to the foilowing Medicare
complaints: #71391; #71515; and #71516.

This visit was to verify correction of
Condition?ievel de?ciencies found during the
hospital compiaint survey on and
12(19-21l2016 in which the facility was found not
in compliance with:

42 CFR 482.12 Governing Body
42 CFR 482.13 Patient Rights

42 CFR 482.21 Quality Assessment and
Performance Improvement

42 CFR 482.25 Pharmaceutical Services

42 CFR 482.41 Physical Environmental

During the course of the follow-up visit, the OCR
surveyors determined that there was a high risk
of serious harm, injury, and death due to the
serious of the findings. This resuited in the

 

 

 

 

 

 

LABORATORY OR REPRESENTATIVES SIGNATURE TITLE (XE) 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 ?ndings and plans of correction are disclosabie 14
days following the date these documents are made availabie to the facility. If deficiencies are cited, an approved pian of correction is requisite to continued
program participation.

FORM CMS-zserroz-oe) Previous Versions Obsolete 27ov12 If continuation shes! Page 7 0f 16

 

 

 

 

 

 

 

 

 

 

 

Printed: 03/23/2017
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (x1) {x3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

NAME CI: woman on SUPPLIER STREETADDRESS, STATE, CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
(M) In SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN OF CORRECTION (x5)
PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE 
TAO OR LSC IDENTIFYING TAG To THE APPROPRIATE DATE
DEFICIENCY)
000} Continued From page 000}
declaration of JEOPARDY in the
following area:
Failure to conduct effective security procedures
when wanding newly admitted patients for
identification of hazards associated with danger
to self and others (3/9/2017 at 2:45 PM).
Removal of the state of EOPARDY
was verified on 3/10r'2017 at 2:10 PM by Paul
Kondrat, RN, MN, Elizabeth Gordon, RN,
MN, Alex Giel, REHS, PHA, and Joy Williams,
RN, BSN.
The hospital remains NOT IN COMPLIANCE with
Medicare Hospital Conditions for Participation for:
42 CFR 482.12 Governing Body
42 CFR 482.13 Patient Rights
Shell 
043} 482.12 GOVERNING BODY 043} A043 482.12 - Governing Body

 

 

There must be an effective governing body that is
legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions speci?ed in this part that pertain to the
governing body

This Condition is not met as evidenced by:

Based on observation, interviews, and document
reviews, the hospital failed to meet the
requirements at 42 CFR 482.l2 Condition of
Participation for Governing Body.

 

 

Immediately following the March 10, 201? exit
summation, the CEO, Governing Board
Member, Chief Nursing Officer/Chief
Operating Officer, Pl/Risk Manager, Director
of Clinical services and Directors of Nursing
reviewed the findings and began formulation
of a plan of correction. The Governing Board
delegated responsibility of ensuring
Completion of all corrective actions to the
CEOlDesignee who along with the Medical
Director is a member of the Governing Board.
The CEO currently conducts a daily
Leadership Meeting which includes reporting
of levels of observation, unusual occurrences,
results of unit rounds and any required

 

 

 

FORM Previous Versions Obsolete

If continuation sheet Page 2 of 16

2

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

Printed: 03I'23l2017
FORM APPROVED
OMB NO. 0938?0391

 

 

 

 

 

 

 

 

 

 

 

 

 

STATEMENT OF DEFICIENCIES {x1} (XE) {x3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

NAME OF PROVIDER OR SUPPLIER STREETADDRESS. STATE, ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
(x4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PLAN OF CORRECTION (x5)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY (EACH CORRECTIVE SHOULD BE 
TAG OR LSC IDENTIFYENG TAG TO THE APPROPRIATE WE
DEFICIENCY)
043} Continued From page 2 043}
corrective actions. The CEOIDesignee is
Faiiure to meet patient rights risks an unsafe responsible reporting the results of
. . . . corrective actlons and use of monitoring
heaithcare enwronment for patients, and .
staff - systems to the fuli Governing Board.
. . . The Performance Improvement Committee wili
Flnd'WS- impiement increased monitoring for any items
. . that do not meet the threshoids that have been
1- The failed *0 established by the Committee. The increased
manage the functioning of the hospitat to protect monitoring will continue unti! compliance is
patients from harm as evidenced by the obtained and sustained for two reporting
JEOPARDY condition identi?ed on periods.
for failure to ensure patients receive
care in an environment in which the safety and See A115. A144. A154 and A285
well-being of patients are assured.
2. Failure to conduct effective safety and security
procedures for identification of hazards
associated with danger to seif and others.
Due to the scope and severity of deficiencies
detailed under 42 CFR 482.13 Condition of
Participation for Patient Rights, the Condition of
Participation for Governing Body was NOT MET.
Cross-Reference: Tags A0115
115} 482.13 PATIENT RIGHTS 115} A115 482.13 - Patient Rights
A hospital must protect and promote each See A144 and A154
patients rights.
This Condition is not met as evidenced by:
Based on observation, interview. record review,
and review of hospital poiicies and procedures,
the hospita! failed to protect and promote patient
rights.
Failure to protect and promote each patient's
rights risk the patient?s loss of persona! freedom,

 

 

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27QV12 If continuation sheet Page 3 of 16

 

 

Printed: 0312392017

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE SERVICES OMB NO. 0938-0391
STATEMENT OF (x1) (le (x3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED

NAME OF OR SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
(x4) rD SUMMARY STATEMENT OF it) PLAN OF CORRECTION {x5}
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE 
TAG OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
115} Continued From page 3 115}
privacy, dignity, and harm.
Findings:
1. Failure to ensure patients receive care in a
safe setting which safeguards vulnerable
individuals from self?harm and harm from others.
2. Failure to utilize the least restrictive alternative
when using seclusion and restraints.
The cumulative effect of these systemic problems
resulted in the hospital's inability to provide for
patient safety and protect patient rights.
Due to the scope and severity of deficiencies
under 42 CFR 482.13, the Condition of
Participation for Patient Rights was NOT MET.
Cross Reference: Tags A0144, A0164
A144 PATIENT RIGHTS: CARE lN SAFE A 144 A144 - Patient Rights= Care in a



The patient has theright to receive care in a safe
setting.

This Standard is not met as evidenced by:

#1 SECURITY PROCEDURES AND
OF HAZARDS

Based on observations, review of manufacturer's
instructions for use, and review of hospital policy

and procedures, hospital staff members failed to

follow manufacturer?s instructions when using the
hand held metal detector.

Failure to ensure that staff are trained and skill
competency veri?ed to operate the hand-held

 

 

 

 

Safe Setting

Security Procedures and identi?cation of

Hazards

Corrective Action:

All staff responsible for wanding patients have
been retrained on (1)the requirement to wand
all individuals admitted to the hospital, (2)the
requirement to wand based on manufacturer
recommendations and "Wanding - Use of
Hand-Held Metal Detector Wand" and
(3)requirement to document completion of
wanding on Nursing Communication Hand-Off
form. Only staff members that have validated
competency have been allowed to perform
procedures as of March 9, 2017.

All
corrective
actions will
be
completed
by April 28,
2017

 

 

 

FORM Previous Versions Obsolete

2TQV1 2

If continuation sheet Page 4 of 16

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE 8: MEDICAID SERVICES

Printed: 03r23r2017
FORM APPROVED
OMB NO. 0938-0391

 

STATEMENT OF 9(1) 
AND PLAN OF CORRECTION IDENTIFICATION NUMBER:
504011

 

 

(X2) MULTIPLE CONSTRUCTION ATE SURVEY
A. COMPLETED


03r10r2017

 

 

 

NAME OF PROVIDER OR SUPPLIER
CASCADE BEHAVIORAL HOSPITAL

 

STREETADDRESS. CITY. STATE. ZIP CODE

12844 MILITARY ROAD SOUTH
TUKWILA, WA 98163

 

 

 

 

meta! detector correctly puts patients. staff, and
visitors at risk for contraband and other
dangerous hazards entering the posing a
serious threat which may result in injury or death.

Reference: Garrett Metal Detector Super Scanner
User Manual.

Findings:

The hospital's poiicy and procedure titled
"Wanding Use of Hand-Hetd Metal Detector
Wand" (Reviewed/2017) stated in partI "Alt
patients will be wanded prior to or immediately
upon arriving on an inpatient unit". The section
titled "Procedure" read in part: ?Staff should not
allow the scanee to influence them as to what is
actually causing an alarm. For instance, if the
detector denotes the presence of a suspicious
item under a shirt sleeve, do not fail to completely
investigate the source of the alarm even though
the scannee assures you that {it} is just hislher
watch." Page 4 of the hospital policy illustrates
the proper technique and procedure to use when
operating the wand; wanding from the front to the
back and ending with the underfoot of the
individual.

The user manual for the Garrett Metal Detector
Super Scanner under the section titled
?Componentle unction" (pp 56) read in part:
"Interface Elimination Button- The detector is
factory set for maximum sensitivity to detect the
smallest of items. The high level of sensitivity
may produce alarms when approaching a floor
containing rebar. Press and hoid this button to
decrease sensitivity to a tevel that does not
respond to the rebar. Reiease button and
detector returns to normai sensitivity."

 

{x4} ID SUMMARY STATEMENT OF ID PLAN OF CORRECTION (XS)
pREFix (EACH DEFICIENCY MUST BE PRECEDED sv FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE 
TAG OR INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE
DEFICIENCY)
A144 Continued From page 4 A144 Continued from page 4

 

Monitoring Plan:
The Directors of Nursing and Director of Intake

or Designee will be responsible for random
weekly audits of staff performing wanding. Any
deficiencies in the wanding procedure will be
identified and staff members retrained on the
spot

The Directors of Nursing will perform 30
random Chart audits of the Nursing
Communication Hand-Off form.

Any adverse findings will be reported in the
Leadership meeting daily and to Governing
Board weekly unit 100% compliance has been
attained for one month. Upon attainment of
100% compliance. monitoring will be reported
to the Pi Committee and quarterly to
the Medical Executive Committee and
Governing Board.

Persons Res onsible:
CEO

Directors of Nursing
Director of Intake
PllRisk Manager

 

 

 

FORM Previous Versions Obsolete

27QV12 If continuation sheet Page 5 of 15

 

Printed: 03:23.:on 7

 

 

 

 

 

 

 

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE 8r. MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF OEFICIENCIES {x1} PROVIDERISUPPLIERICLIA MULTIPLE {x3} DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

504-011 B. WING 
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98158
(x4) ID SUMMARY STATEMENT OF Io PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDEO BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE 
TAG on 1.30 IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE

A 144 Continued From page 5 A 144

2. On 3i7l2017 between 8:00 PM and 8:28 PM,
Surveyor #1 requested a certi?ed nurse's aide
(CNA) (Staff Member to demonstrate the use
of the hand-held metal detector. During the
observation, the CNA turned the metal detector
on and the metal detector appeared to be
malfunctioning with the surveyor noting that all
LED lights were flashing on and Off. Staff Member
#2 pushed a button on the side of the metal
detector and the fiashing LED tights shut off
except for a single green light. The CNA then
proceeded to scan the surveyor while
continuously holding (depressing) the side button.

Staff Member #2 acknowledged in a foitow-up
interview with Surveyor #1 that hefshe was
unaware of the Side button's function or purpose.

3. On 31812017 at 9:00 AM, Surveyor #1
interviewed the Director of Intake Personnel (Staff
Member about the use of hand-heid metal
detectors and training of personnel. Sihe
confirmed the metai detector used on 3i712017 by
Staff Member #2 had maltunctioned and the
battery had been replaced. The hospitai did not
have a system in piace to check the battery

status of the hospitai's eight metal detectors.

4. On 3i10f2017 between 11:00 AM and 11:45
AM, Surveyor #1 observed an intake Personnei
staff member (Staff Member demonstrate the
use of the hand-held metal detector wand. During
the observation, Staff Member #3 pushed the
Side button (interference elimination button) and
proceeded to wand the front of the patient. The
metal detector beeped and a red light flashed
when the wand was located near the patient's
feet. Staff Member #3 asked the patient (Patient
if they had anything in hisiher socks. Patient
#5 stated Staff Member #3 continued the

 

 

 

 

 

 

 

FORM Previous Versions Obsolete 27QV12 If continuation sheet Page 6 0f ?35

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

Printed: 03/23/2017
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

 

 

wanding procedure to include both sides of the
patient (left and right). Staff Member #3 did not
wand the backside (posterior aspect) of the
patient as required by hospital policy. The staff
member failed to wand the underside of the
patient?s feet or investigate further the source of
the beeping as required by hospital poiicy.

5. On 3l1U/2017 at 2:30 PM, Surveyor #1
reviewed eight medical records and the "intake to
Nursing Communication Hand-Off" forms and
noted the foliowing:

a. Four of eight records reviewed were not
marked "Yes" or "No? to document and confirm
the patient had been wanded.

b. One of eight records reviewed was marked
"No" reflecting that the patient had not been
wanded.

C. Three of the eight records reviewed were
marked "Yes" indicating the patient had been
wanded on admissiOn. Upon further review, the
surveyor found:

1. Patient #3 had a metal "X-Acto: blade"
found after the patient had done harm to self by
cutting themselves. The record indicated the
patient acknowledged hiding the metal blade in
hisiher sock.

2. Patient #6 had a celiuiar phone found
during the skini'clothing check by the nursing staff
upon arrival on the unit.

3. Patient had a ceilular phone discovered
on the day of discharge after a five day hospital
stay.

 

 

 

 

STATEMENT OF DEFICIENCEES (x1) MULTIPLE {x33 DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING COMPLETED

NAME OF PROVIDER CR SUPPLIER STREETADDRESS. CITY. STATE. CODE
CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH
- TUKWILA, WA 98168
in SUMMARY STATEMENT OF in PROVIDERS PLAN OF CORRECTEON (Ks)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY CORRECTIVE ACTION SHOULD BE 
TAG OR [.80 IDENTIFYING TAO CROSS-REFERENCED TO THE APPROPRIATE

A 144 Continued From page 6 A 144

 

 

 

FORM Previous Versions Obsolete

2YQV12

ll' Continuation sheet Page 7 of 16

 

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE MEDICAID SERVICES

Printed:

031232017

FORM APPROVED
OMB ND. 09338-0391

 

 

 

 

 

 

 

 

 

 

 

#2 LINE OF SIGHT MONITORING

Based on record review and review Of hospital
policy and procedures, the hospital failed to
ensure that patients on "Line of Sight" (LOS)
observation were kept safe from seif-harm or
injury from other patients.

Failure to protect patients from self-harm and
harm by other patients may iead to serious injury
or death.

Findings:

1. The hospital's policy and procedure titled,
"Patient Observation"(Policy 
Reviewed 112017) stated in part, . .ill. Levels of
Observation. . . 8. Line of Sight. The patient will
be kept within eyesight and accessible at all
times, day and night. Tools or instruments that
could be used to harm themselves or others
should be removed. This level of observation is
required when the patient could, at any time,
make an attempt to harm themseives or others.
Positive engagement with the patient is an
essentiai aspect of this level of observation."

The hospitai policy and procedure titled. "Patient
Rights and Responsibilities" (Policy 
Reviewed 12?2017) stated in part: . . Procedure .
. . B. The list Of patient rights shall include but are
not limited to the following: . . . 5. The right to
receive care in a safe setting."

 

 

STATEMENT OF (x1) PROVIDERISUPPLEERICLIA 9(2) (x3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: A. BUILDING COMPLETED
NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP 
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
out) In SUMMARY STATEMENT OF In PLAN OF CORRECTION (X5)
DEFICIENCY MOST BE BY FULL REGULATORY (EACH CORRECTIVE ACTION SHOULD BE 
TAG OR IDENTIFYING TAG CROSS-REFERENCEO TO THE DATE
DEFICIENCY)
A 144 Continued From page 7' A 144

Line of Sight Monitoring

Corrective Action:

Policy PC.P.300was reviewed and revised to
(1)ciarify that L08 monitoring be assigned to a
specific staff member. (2)0larify that the patient
must be visible to the assigned staff member at
all times. (3)the staff member must take action
to prevent potential for patient to harm self or
others. and (4)staff must document efforts to
prevent harm in the patient record.
Reeducation was initiated for all staff
responsible for monitoring observation levels of
patients' regarding the changes to the policy.
RNs were reeducated on their ability to
increase a patient?s level of observation without
a physician order and all staff performing
observations were reeducation on the risk
factors for each level of precaution.

Monitoring Plan:
The Directors of Nursing/Designee will

conduct rounds each shift on each unit to
ensure monitoring is performed as ordered.
Failure to perform monitoring as expected will
be immediately addressed. Results of
Observations will be reported daily in the
Leadership meeting and weekly to the
Governing Board until monitoring is
maintained at 100% for one month. Upon
attainment of 100% compliance, results will be
reported to the Pl Committee and
quarterly to Medical Executive Committee and
Governing Board.

Persons Responsible:

 

 

 

CEO
2. Patient #3 was an 18 year-Old admitted on Directors of Nursing
2.1241201? for treatment of depression with Manager
suicidal ideation. The patient received a score of
40 on the Suicide Assessment scale which was
completed on admission. A review of the overall
risk level scoring tool indicated that medium risk
FORM Previous Versions Obsoiete 27QV12 if continuation sheet Page 8 0f 13

 

 

 

 

 

 

 

 

 

 

Printed: 03123/2017
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID SERVFCES OMB N0. 0938-0391
STATEMENT OF DEFICIENCIES (x1) 9?21 (x3) DATE SURVEY
AND PLAN OF IDENTIFICATION NUMBER: A. COMPLETED

NAME OF OR SUPPLIER STREETADORESS, chv. STATE. ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
{x4} 10 SUMMARY STATEMENT OF DEFICIENCIES in PLAN OF CORRECTION (x5)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVEACTION SHOULD BE 
TAG OR IDENTIFYING INFORMATION) TAG CROSSREFERENCED To THE APPROPRIATE 
DEFICIENCY)
A 144 Continued From page 8 A 144

is Classi?ed as a score between 25 and 41. Other
than the routine every 15 minute checks that are
completed for all patients on the unit, no speciai
observation status was assigned until after the
physician had examined the patient on the
following day (2(2512017) after which the patient
was placed on line of sight (L08).

3. On 212712017 at 10:00 PM, a Registered Nurse
(RN) (Staff Member entered a note into the
patient?s medicat record stating that the RN had
examined the patient and found multiple cuts on
herfhis ieft wrist and arm. The RN notified the
patient's physician. A teiephone order
documented by the RN on 2(27l2017 at 9:30 PM
stated that the patient was on L08 observation
status and that the patient was responsible for
remaining in 1.08 of assigned staff. The patient's
physician had ordered LOS observation status
earlier in the day at 2:25 PM as well. The RN
phone cat! to the physician about herlhis
concerns reiated to the patient?s self?harm did not
result in an order for increased monitoring of the
patient.

4. Review of a physician (Staff Member note
dated 312201? at 1:00 PM showed the physician
assessed the patient to have an increased
suicide risk. The physician ordered increased
staff monitoring Of the patient. The physician's
order dated 3i2l2017 at 10:45 AM stated 
{every} 5-minute Checks for 24 hours."

5. According to documentation, on 3121?201??
around 10:00 PM. a licensed nurse (Staff
Member found that Patient #3 was bleeding in
the area of herlhis left area. The
patient was noted to be sitting on the floor with a
bianket covering herlhis arm. initially, Patient #3
stated shelhe cut themselves using a pencil.

 

 

 

 

 

 

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27QV12

If continuation sheet Page 9 of 16

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE 8: MEDICAID SERVICES

Printed:

03123/201??
FORM APPROVED

OMB NO. 0938-0391

 

STATEMENT OF DEFICIENCEES
AND PLAN OF CORRECTION

0(1) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:

504011

 

 

MULTIPLE CONSTRUCTION
A. BUILDING

B. WING

 

 

(X3) DATE SURVEY
COMPLETED


03110I2017

 

NAME OF PROVIDER 0R SUPPLIER
CASCADE BEHAVIORAL HOSPITAL

 

STREET ADDRESS. CITY. STATE, ZIP CODE

12844 MILITARY ROAD SOUTH
TUKWILA, WA 98163

 

 

After further questioning, it was discovered that
the patient had used a metat blade {X-Acto
biade}. The patient reported that shelhe kept the
blade hidden in herihis sock.

6. Review of documentation dated 3I2l2017 at

11 :00 PM, foilowing the blade cutting incident,
reveaied that staff felt the patient should have
been in 1:1 observation status because while the
patient was in LOS of staff and on every 5 minute
checks the incident stilt occurred.

7. An interview with a RN (Staff Member on
318201? at 3:20 PM with Surveyor #2 showed
that shelhe felt that Patient #3 should have been
on 1:1 observation status as the patient had a
history of grabbing pencils and using them to
harm herself/himseif even though shelhe was on
1.08 observation status. Staff Member #7 aiso
reported that Patient #3 harmed themself with a
meta! blade while on LOS observation status with
every 5 minute Checks.

8. An interview with the Director of the Adult
Unit (Staff Member #10) on 31912017
at 10:40 AM con?rmed the incident related to
Patient Staff Member #10 revealed that
sheihe was unsure how Patient #3 came to be in
possession of such a dangerous object. Staff
Member #10 stated that Patient #3 told staff that
shefhe brought the blade from home.

9. On at 10:00 AM, Surveyor #4
reviewed the inpatient record of Patient She
was admitted on $131201? due to concerns that
the patient might harm themselves. Patient #4
was initially placed on observation from
213201 to 21812017. and then was placed on
LOS observation for safety. The patient
remained on LOS observation until $812017. An

 

 

 

 

(x4) ID SUMMARY STATEMENT OF PLAN OF CORRECTION 0(5)
PREFIX DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG OR LSC INFORMATION) TAG CROSS-REFERENCEO To THE DATE
DEFICIENCY)
A 144 Continued From page 9 A 144

 

 

 

FORM Previous Versions Obsolete

2

If continuation sheet Page 10 of 16

 

 

 

 

 

 

 

 

 

 

Printed: 03931201?
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF {x1} 9?2} CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION NUMBER: A. COMPLETED

504011 3- WING 03f10f2017
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, STATE. ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 93168
(x4) ID SUMMARY STATEMENT OF ID PROVIDERS PLAN OF CORRECTION (XS)
PREFIX (EACH DEFICIENCY MUST BE PRECEDEO BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE 
TAG OR IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE

A 144 Continued From page 10 A144

entry in the medical record by a registered nurse
(Staff Member dated 3/712017 at 5:37 PM
documented "Pt. (alert and oriented) x3.
Mood is anxious and resttess. Pacing about unit.
Approached nurse with blood streaming down 
(right) forearm from self-inflicted injury." The
self-harm injury sustained by Patient #4 occurred
while the patient was ordered for 1.08. No other
documentation in the medicat record was found
to indicate the hospital staff attempted to stop the
patient from harming themselves prior to the
patient presenting themselves to the nursing staff.

10. On 3192017 at 9:15 AM, Surveyor #3
reviewed the medicai records of three patients
who were involved in a total of eight patient on
patient assault incidents of which five occurred
while on LOS monitoring. The surveyor noted the
following:

a. On 325201 7 at 6:15 AM, Patient #8 while on
LOS monitoring was noted in the record to be
"exiting seeking, frequentiy trying to open doors . .
.Pt [patient] is observed wandering into peers
bedroom 8: taking their belongs. Staff stated that
pt. was observed punching a much targer peer
who assaulted him back. Staff was abie to break
up the argument 8: redirect pt's to different
iocations."

b. On $111201? at 9:45 PM, Patient #2 white on
L08 monitoring was noted in the record as
"Patient threw a punch and knocked . . . patient to
the ground . . Police officers arrived in unit {to}
investigate the case. . .Patient medicated PRN
{as needed} meds. Remain in room for a while
untii the second patient transferred for safety".

11. On 3!?!201? at 9:15 AM, Surveyor #3
interviewed a registered nurse (Staff Member 

 

 

 

 

 

 

 

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270V12

lfcontinuation sheet Page 11 arts

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

Printed: 039322017
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

 

 

 

 

SECLUSION

Restraint or seclusion may only be used when
less restrictive interventions have been
determined to be ineffective to protect the patient,
a staff member, or others from harm.

This Standard is not met as evidenced by:

Based on record review and review of hospital
policies and procedures. the hospital staff failed
to consider the effectiveness of less restrictive
interventions before applying simultaneously both
restraints and seclusion for 3 of 6 patients
reviewed. (Patients 

Failure to utilize or consider less restrictive
alternatives to using both restraints and seclusion
simultaneously puts patients at risk for loss of
personal freedom and dignity.

 

 

STATEMENT OF DEFICIENCIES (x1) (X2) {x3} OATE SURVEY
AND PLAN OF NUMBER: A. BUILDING COMPLETED

504011 a. WING 03110i2017
NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
ID SUMMARY STATEMENT OF DEFICEENCIES Io PROVIDERS PLAN OF CORRECTION (x5)
PREFIX MUST BE PRECEDED BY FULL REGULATORY PREFIX CORRECTIVE ACTION SHOULD BE 
TAG OR IDENTIFYING TAG TO THE APPROPRIATE
. DEFICIENCY)
A 144 Continued From page 11 A 144
about the different levels of observation and the
difference between them. The nurse indicated
that L03 is similar to the 15 minute checks with
the entire staff and no one person responsible for
the monitoring. Staff Member #6 acknowledged
that only when a patient is ordered for 1:1
monitoring is a specific individual assigned to
monitor the patient.
12. An interview with the Director of Quality and
Risk (Staff Member #11) with Surveyor #2
revealed that the facility was not collecting data
on the use and effectiveness of levels of
observation (Le. LOS, 1:1) of patients. Heishe
also stated that there were no current
improvement projects concerning LOS and 1:1
patient monitoring.
164} PATIENT RIGHTS: RESTRAINT OR 164}

A164 Patient Rights: Restraint
or Seclusion

Utilize least restrictive alternative when using 

 

restraint or seclusion corrective i
actions will 
Corrective Action: be i 
Policy PC.R.100 "Seclusion and Physical 8t :21: arts
Mechanical Restraint? was reviewed on than ril
March 10, 2017 and providers and staff were 28 20:7

reeducated regarding the requirement to
utilize and document the utilization of the
least restrictive alternative when using
restraints or seclusion.

 

 

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27QV12 If continuation sheet Page 12 of 16

 

 

 

DEPARTMENT OF HEALTH AND HUMAN 
CENTERS FOR MEDICARE MEDICAID SERVICES

Printed: 0312312017
FORM APPROVED
OMB NO. 0938-0391

 

 

 

 

 

 

 

 

 

Findings:

1. The hospital policy and procedure titled
"Seciusion and Physical Mechanical Restraint"
(Reviewed 112017; Policy PC.R.100) under the
section "Policy" read in part: "Seclusion and
restraints may only be used for the management
of violent or self-destructive behavior that
jeOpardizes the immediate physicai safety of the
patient, a staff member or others after
iess-restrictive interventions are ineffective or
ruled-out. . . 

The section titled "Patient Rights" read in part:
"Restraint or seclusion may only be used when
less restrictive interventions have been
determined to be ineffective to protect the patient
or others from harm. The type of technique of
restraint or seclusion used must be the least
restrictive intervention that will be effective to
protect the patient, a staff member, or others
from harm."

2. On 382le7 at 9:15 AM, Surveyors #3 and #4
reviewed the records of ?ve patients who were
placed in either seclusion or restraints during their
hospital stay and noted the foliowing:

a. Patient #1 was placed in 4-point restraints and
seclusion simultaneously by hospital staff on
21912017 at 7:45 PM. Subsequently, Patient #1
was released from restraints at 9:15 PM and from
seclusion at 10:45 PM. No documentation
indicating that a less restrictive atternative had
been considered or attempted first prior to the
simultaneous application of both physical
restraints and seclusion could be found.

b. Patient #2 was placed in 4-point restraints and
seclusion simultaneously by hospital staff on

 

 

 

STATEMENT OF DEFICIENCIES (x1) (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF NUMBER: A. BUILDING COMPLETED

NAME OF PROVIDER OR SUPPLIER STREETADDRESS, CITY, STATE, ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12344 MILITARY ROAD SOUTH
TUKWILA, WA 98163
{x4} IO SUMMARY STATEMENT OF In PROVIDERS PLAN OF CORRECTION (Xe
PREFIX (EACH MUST BE BY FULL REGULATORY CORRECTIVE ACTION SHOULD BE if; 
TAG OR 1.50 IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE

164} Continued From page 12 164}

- will be immediately addressed with staff

 

Monitoring Plan:
The Directors of Nursing/Designee will

perform audits on each incident of restraint
or seclusion. Failure to adhere to PC3100

involved in the incident. Results of the audits
will be reported daily in Leadership meeting,
and weekly to the Governing Board until
monitoring is maintained at 100% for one
month. Upon attainment of 100%
monitoring, results of audits will continue to
be reported in Leadership but be
reported to the Pi Committee and
quarterly to Medical Executive Committee
and Governing Boa rd.

Persons Responsible:
CEO

Directors of Nursing
Director of lnta ke

Pl/ Risk Manager

 

 

 

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27QV12 if continuation sheet Page 13 of 18

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE 8: SERVICES

Printed: 024232017
FORM APPROVED
0MB NO. 0938-0391

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATEMENT OF (x1) PROVIDERISUPPLIERICLIA (X2) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. COMPLETED

504011 03H 0i2017
NAME OF PROVIDER DR SUPPLIER STREETADDRESS, STATE. CODE
CASCADE BEHAVIORAL HOSPITAL 12844 ROAD SOUTH
TUKWILA, WA 98168
IO SUMMARY STATEMENT OF DEFICIENCIES rD PROVIDERS PLAN OF CORRECTION (XS)
PREFIX (EACH DEFICIENCY MUST BE PRECEDED EIY FULL REGULATORY PREFIX CORRECTIVEACTION SHOULD BE COMPLETION
TAG on Lee IDENTIFYING INFORMATION) TAG TO THE APPROPRIATE DATE

164} Continued From page 13 164}
225201? at 6:00 PM. Subsequentiy. Patient #2
was released from restraints at 9:00 PM and from
sectusion at 9:45 PM. No documentation
indicating that a less restrictive alternative had
been considered or attempted ?rst prior to the
simultaneous application of both physical
restraints and seclusion could be found.
3. During the survey, Surveyor #2 toured the Adult
Unit 2 West and reviewed the medical
record of Patient The surveyor noted the
patient was ordered for both seclusion and
4-point restraints simultaneously on 3i2i2017,
3f3i2017, and 13/612017 respectively. NO
documentation couid be located in the medical
record to indicate a less restrictive technique
(either seclusion or restraint used atone) was A286 E3 Patient Safety
attempted prior to the simuitaneous application Of
both physical restraints and seclusion. Program Scope, Activities and Executive
Responsibilities 
286} (OX2), PATIENT SAFETY 286} corrective
Standard: Program Scope ?Corrective Action: . . 32mm 
(1) The program must include, but not be iimited PVRM was reeducated on the fac'l'ty . completed -
to, an ongoing program that shows measurable Performance Plan on March 29' 2917 Wh'Ch no later
improvement in indicators for which there is includes the objectIves t0: (liachieve an than April
evidence that it will identify and reduce effective reduction of medical/heaith care 23? 2017
medicai errors. errors and other factors that contribute to
(2) The hospital must measure. analyze, and unintended adverse patient outcomes
track madverse patient events (2)providing an effective, pianned, systematic
mechanism to design, measure, assess and
(C) Program Activities improve the performance of the facility (3}to
(2) Performance improvement activities must facilitate a proactive approach toward
track medical errors and adverse patient events, continuous quality improvement and evaluate
analyze their causes, and implement preventive actions ta ken to assure that desired resutts
actions and mechanisms that include feedback are aChiEVE??d and sustained (4}t0 promote
and learning throughout the hospital. communication and reporting of performance
improvement activities by and between
Executive The hospital?s departments, administration, medical staff,
governing body (or organized group or individual Governing Board and others as deemed
who assumes fuii legal authority and necessary.
FORM Previous Versions Obsoiete 270V12 if wnlinua?on sheet Page 14 0t 16

 

 

Printed: 031231201?
FORM APPROVED
OMB NO. 0938-0391

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE MEDICAID SERVICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATEMENT OF {x1} 9?2) CONSTRUCVON DATE SURVEY
AND PLAN OF CORRECTION NUMBER: A. COMPLETED

504011 B. WING 03110i201'i"
NAME OF PROVIDER OR SUPPLIER STREETADDRESS. CITY, STATE, ZIP CODE
CASCADE BEHAVIORAL HOSPITAL 12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES Io PROVIDERS PLAN OF CORRECTION (XS)
(EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY CORRECTIVE ACTION SHOULD BE 
TAG OR IDENTIFYING INFORMATION) TAG To THE APPROPRIATE DATE

286} Continued From page 14 286}
responsibility for operations of the hospital), MM
medical staff, and administrative officials are Unusuai occurrences wilt be reported daily in
responsibie and accountable for ensuring the Leadership, weekiy to Governing Board and
following: investigated by the Incidents will be
(3) That clear expectations for safety are tracked, trended and reported by Pl/ RM
established. along with plans for improvement to
Pi Committee and quarterly to Medical
Executive Committee and Governing Board.
Persons Responsibie:
This Standard is not met as evidenced by: CEO
Based on interview, record review and review of Pi/Risk Manager
policy and procedure, the hospital taiied to track
and document the staff response to a patient's
cardiac arrest event as required by hospital policy
and procedure.
Failure to document a patient's cardiac arrest
event decreases the quality of the information the
hospital can provide for ongoing treatment of the
patient and leaves the hospital unable to evaiuate
the effectiveness of emergency response for
quality improvement purposes.
Findings:
1. The hospital?s policy and procedure titled
"Code Blue" Reviewed
112017) stated that a patient cardiac arrest should
be documented on the Code Biue Record and
piaced in the patient?s medicai record.
2. Patient #9 was a 49 year-Old admitted on
131912016 for treatment of alcohol use disorder.
Patient #9 required treatment for alcohot
withdrawal and was admitted to the detoxification
unit. On 12(21l2016 at 12:54 PM the patient was
found unresponsive and cyanotic (bluish
discoloration of the skin). At the same time, Staff
called a Code Blue (a code used in hospitals for
FORM Previous Versions Obsolete 27ov12 if continuation sheet Page 15 0f 16

 

 

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE 8: MEDICAID SERVICES

Printed: 032312017
FORM APPROVED
OMB NO. 0938-0391

 

STATEMENT OF 
AND PLAN OF CORRECTION

(X1) 
IDENTIFICATION NUMBER:

504011

 

(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY

A. BUILDING COMPLETED

03(1012017

 

 

 

 

NAME OF PROVIDER OR SUPPLIER
CASCADE BEHAVIORAL HOSPITAL

 

STREETADDRESS. CITY. STATE, ZIP CODE

12844 MILITARY ROAD SOUTH
TUKWILA, WA 98168

 

0(5)

 

 

 

9(4) Io SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDERS PLAN or 
PREFIX (EACH MUST BE PRECEDED BY FULL REGULATORY PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
TAG OR LSC IDENTIFYENG INFORMATION) TAG TO THE APPROPRIATE DATE
DEFICIENCY)
286} Continued From page 15 286} .
medical emergencies) and started A286 E3 Patient Safety
cardiopulmonary resuscitation (CPR). 
Paramedics arrived at 1:10 PM and continued W0 ue Ail
administerin CPR until the atient was -
pronounced E:chead at 1:40 Pit: 9mm corrective
PC.C.100 "Code Blue? was reviewed and ail :ctrons .
. . . 
Review of Patient #9'8 medical record reveaied nursmg staff retrained regarding completed 5
that there was no detailed record (Code blue documentation requirements and forms to be no later
Record) of the staff response to the patient's Ut'hzed? Gorng forward the than April
cardiac arrest. conduct annuai mock Code Blue drills. 28, 2017

3. An interview with the Chief Operating Officer
(Staff Member #12) on 318201? at 10:10 AM
con?rmed these findings.

MID?nitomgm
All Code Biue incidents will be reviewed by

and a staff debrief conducted post
incident to ensure documentation
requirements have been met. Adverse
findings will be reported in Leadership daily
and results of investigations, action plans and
chart audits will be reported to PI
Committee and quarterly to Medical
Executive Committee and Governing Boa rd.

Persons Responsibie:
CEO

Pl/ Risk Manager

 

 

 

 

 

 

 

FORM Previous Versions Obsolete

270V12 If continuation sheet Page 16 of 16