PRINTED: 11/27/2017 FORM APPROVED s ta te of Waahington STATEMENT OP OEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPLIERrCLIA IDENTIFICATION NUMDER CASCADE BEHAVIORAL HOSPrTAL CX^ID PREFIX TAQ (X3) DATE SURVEY COIiff>L£TED A BUILDlNa-. a. WING 60429197 NAME OF PRCVIOB^ OR SUPPLIER (X3) MULTIPLE CONSTRUCTION 1 1/02/201 1 /02/201 7 STREET ADDRESS, CITY, STATE, 23P CODE TUKWILA, WA 981 66 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC (DEKHFYING INFORMATION) LOGO INITIAL COMMENTS ID PREFIX TAG PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCa>TOTHE APPROPRIATE DEFICIENCY) 0(6) COMPLETE OA-re LOOO STATE UCENSING SURVEY The Washington State Department of Health (DOH) In accordance with V\/ashington Administrative Cede (WAG), Chapter 246-322 Vi^C Private Psychiatric and Alcoholism Hospitals, conducted this health and safety survey. Onslte dates; 1 0/31 /1 7 to 1 1 /2/1 7 The survey was conducted by: Joyce V^lliams, BSN, RN Klmberly Metz, MSN, BSN. RN Lisa Mahoney, MPH, PHA The Washington Fire Protection Bureau conducted the fire life safety inspection on 10/31 /2017 During the course of the survey,-surveyors assessed Issues related to complaint #201 7-1 31 48. The complaint was not substantiated. ASE#9J871 1 L200 322-030.1 Dlsdosure Slalement L200 L20Q 322-030.1 DISCLOSURE STATEMENT WAC 246-322-Q30 Criminal history, disclosure, and bacKground Inquiries. (1 ) The licensea or license applicant shall require a disclosure statement as defined In RCW 43.43.834 for each prc>spective employee, volunteer, conbBCtor, student, and any other Individual associated with the hospital ha>ring direct contact with HOW: The licensee wOl acquire a disclosure statemenl as defined In RCW 43.43.834 for all prospecQve employees, vohinleere, contractors, students, and any other individual assodaled with Ihe hospHal having direct conlact with vulnerable adults. WHO: Director of Human Resources StBloFonn2SS7 LABORATORY DIREGTORS OR PROVIDER/SUPPUB^ REPRESENTATIVE'8 SIGNATURE served the patient had no fall wrist band, and there was no chair alarm or bad alarm in place. 3. On 10/31/17 at 10:02 AM, Surveyor #3 and a Registered Nurse (Staff #2) review^ the medical record for Patient #1 . The record review showed that on admission to the hospital, staff assessed the patient as a high risk for fell, related to unsteady gait and use of a wheelchair. The "Fall Treatment Plan" completed on 1 0/26/1 7 showed that nursing staff were to Implement foil precautions that Induded a foil wristband, bed alarm and chair alarm. The "Nurse Daily Patient Reassessments" ccmpleted on day shift and state Form2567 STATE FORM 9JB71 1 n BonUnuBilan shael 4 n ri6 SPECIAL REQUEST 2018-130235 PAGE 269 PRIKTTED: 11/27/2017 FORM APPROVED state of Vtoshingtgn STATEMENT OF DP.FlCIENCiES AND PLAN OF CORRECTION 0(1 ) PROVIDER/SUPPUETOCLIA IDENTIFICATION NUMBER: CASCADE BEHAVIORAL HOSPITAL 9(4)1 0 PREFIX TAG A. BUILDING: 9(3) DATE SURVEY COMPLETED B. WING. 60429197 NAME OF PROVDER OR SUPPLIER 9(2} MULTIPLE CONSTRUCTION 1 1 /02/201 7 STREET ADDRESS, CITY. STATE, ZIP CODE 1 2844 MILITARY ROAD SOUTH TUKWILA.WA 891 68 SUMMMTY STATEMENT OF KRCIENOES (EACH DEFIQENCY MUST BE PRECEDED BY FU a REGULATORY OR ISC IDENTIFYING INFORMATION) L31S Continued From page 4 in PRDVIDGR'B PLAN OF CiORRECTION (EACH CORRECTIVEACTION SHOULD BE CROSS-REFBIENCED TO THE APPROPHIATE DEFICIENCY) PREFIX TAG (XB) (XIMPLiiTE DATE L31 5 evening stiifl on 1 0/27/1 7,1 0/28/1 7,1 0/29/1 7, and 10/30/17 showed that the patient was a high risk for fell. A. During an Interwew with Surveyor #3 at the time of the record review, Staff #2 told Surveyor V3 that the patient had removed the wrist band the previous night. The patient had been pulling at the alarm and it was causing the patient to be agitated, so the elann was removed. Surveyor. #3 and Staff #2 found no documentation In the madical record "High Risk Fall" Interventions had been removed or the patlente risk for fell had changed. At t he time of the record review. S taff #2 stated that the patient should have been reassessed and the "Fall Treatment Plan" modified. 5. During dosed medical record review, Surveyor #1 rewewed the chart of Patient #2, an 85 year old female admitted on 09/28/1 7 for dementia, behavior Issues and anxiety. The psychiatric progress note on 1 0/05/1 7 stated that the patient had an unstable gait and stooped posture when ambulating. The patient was evaluated as being at high risk for a fail. At 4:55 AM on 10K)5/17 the nursing notes stated that the patient had an unwitnessed fall. The record Indicated the patient was on "Fall Precautions" and had a yellow wrist band. There was no rscord that a bed aiomi was in place as per policy. Staff were to check the patient every 1 5 minutes, but the surveyor observed that there were alterations in the record betviraen 4:30 and 5:00 AM, indicating that the patient was "lying/sitting". Instead of "eyas closed, oven respirations^. 6. On 11/02/17 at 11:00 AM, the chart was reviewed with the Director of Nurses (Staff #3) who agreed that the record had been altered to StBta Pom 2S67 STATE FORM 9J871i llcDnllruBtiontfiBat S oflS SPECIAL REQUEST 2018-130235 PAGE 270 PRINTTED: 1 1 /27/201 7 FORM APPRO/ED Slate of Wbshinaton STATEMtiNr OF DEFICIENCIES AND PLAN OF CORRnCTION (XI) PROVOER/SUPPLIER^CUA IDENrFICATiON NUMBi3«; CASCADE BEHAVIORAL HOSPITAL (X4)ID PREFIX TAO A. BUILDINQ: (X^DATESURVEV COUPLETED B. VMNG. 604291 97 NAME OF PROVIDER OR SUPPUER (X9 MULTIPLE CONSTRUCTION 1 1 /02/201 7 STREET ADDRESS, CrTY. STATE. ZIP CODE 1 2844 MILITARY ROAD SOUTH TUKWILA,WA 9B1 68 8UMMARV STATEMENT OF DEFICIENCIES (EACH DEFiaENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC mENRFYING INFORMATION) L31 5 Continued From page 6 PROVIDER'S PIAN OF CORRECTION (EACH C0RRfKni\AIAC1 1 0N SHOULD BE CROS&REFERENCED TO THE APPR0PKIA1 E DEnCIENCY) ID i>KEFIX TAG COMPLETE HATE L31 S change the cljseivation outcome around the time ofthepationt's fall. 7. On 1 1 /02/1 7 at 1 0:30 AM during review of the faclllt/s Quality Program, Surveyor #1 noted that patient b ll rates were an indicator that the facllily leadership had chosen as a focus area. The Director of Nursing (Staff #3) stated that the patient fell rate had been Identified as an outlier In their quality measures. The facility put together a task force to evaluate the fall rate and had identified that the current Fall Risk /Assessment Tool (Morse) was not based on the evaluation of a psychiatric patient popuiaiion. TTia facility is ado^ng a new tool for evaluab'ng the fall risk of patients in the psychiatric setting (Wilson-Slms). The Director of Nursing stated that the task force pfanned to continue to monitor fsll rates and determine If the VVIIson-Sims Fall Assessment Tool decreased the rate of foils In the focllity. Item #2 Pain Assessment and Reassessment Based on inten/lew, and review of the psydilatric hospital policies and procedures, the hospital foil^ to ensure staff members completed and documented pain assessment, and reassessments after each pain management intervention, as directed by hospital policy for 4 of 4 patient records reviewed (Patients #1 . #4, and #5). Failure to assess, treat and reassess a patient's pain places the petisnt at ifsk for a delay in treatment and may result in patient hami. L315 322.035.1 C PoHcles-Treatniont Item S2: Pain Assessment/Reassessment HOW:* SlafTwere educated In a staff meeting for all nursing staff on/between 1 2.1 9-1 2.23.1 7. A Handout given that descrlbea (with an example) using PIE for adequate documentation of any score groaior than 3 or which requires Intervanfiona. All dinlcel staff will tie educated to the Importance of documenting pain assessment, reassessment, and pain management tntervenlions. WHO:Chlef Nursing OfRcer (CNO) WHAT: The CNO or designee will be responsible for ensuring that patients have appropriate pain assessment, reassessment, and pain management interventions. The CNO or designee v4ll audk patients who require pm medkaltons for pa'n. 50 ctiarts win be audited monthly for ttils measure with a oompHanoe goal of fOO peroent. Audit results wtfl be reported monthty to Perfbrmanco knpFOvement Conwnlttee and quarterly to MEC and Govcming Board. Monthly audits will continue until 10Q percent compliance can be maintained for a period of two consocutlve months, after which a quarterly audit will be conducted. Any Item below 1 00 percent will require an action ^an. WHEN: AO correedva actions wOl be compleled by 01-03-2018 Findings included: 1 . The psychiatric hospftal's policy titled, "Pain Management,' Policy # PC.P.iOO reviewed on Sinie Form 2567 STATE FORM eJ6711 IToMlnuaUanilMiat eefiS SPECIAL REQUEST 2018-130235 PAGE 271 PRINTED: 1 1 /27/201 7 FORM APPROVED StatQofimashinQton BTATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (XI) PROVIOER/aUPPLIBRAXIA IDENTIFICATION NUMBER: CASCADE BEHAVIORAL HOSPITAL 1 X4) ID PREFIX TAG L31 5 A. BUILdNQ: (X3) DATE SURVEY COMPLETED 8. VUNG 60429197 NAME OF PROVIDB^ OR SUPPLIER (X2) Mm.HPLE CONSTRlXXnON 1 1 /02/201 7 ST1 ^ETA[)DRE8S,CITY, STATE, ZIP CODE 1 2844 MILITARY ROAD SOUTH TUKWILA, WA 981 88 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFIOENCY MUST BE PRECEDED BY FULL REGULAFORY OR LSCIDENTIFYINO INFORMATION) Continued From page 6 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEnCENCY) ID PREFIX TAG (XQ COMPLETE DATE L31 5 01 /1 7, showed that pain assessment Includes Iccatlon, Intensity, duration, quality and character using appropriate scales, the patient's acceptable level of pain, effectiveness of the plan and the patient responses to pain Interventions. 2. On 10/31 /1 7 at 9:30 AM, Surveyor #3 and a Registered Nurse (Staff #2} Fevlewed the medical record of Patient #1 who had been admitted on 1 0/26/1 7 for the treatment of Bipolar Mania. The review of the "Nurse Daily Patient Reassessmenf' form showed on 1 0/29/1 7 at 5:00 AM the patient received acetaminophen 650 mg for complaints of 'general discomfort". The documented response was "effective". Surveyor#3 found no evidence the patient's pain had been assessed for intensity, duration, quality and character using appropriate scales prior to ttie intervention, it Is unclear when the pain reassessment was completed. The Pain Assessment section of the form for day shift shows a pain rating of "YVIO." The sections labeiied "quality", "pattern", and "reassessmenf were blank. On the same day at 7:1 5 PM, ftre patient received acetaminophen 650 mg for complaint of "back pain". At 7:45 PM the documented response was "effective". Surveyor #3 found no evidence the patients pain had been assessed for Intensity, duration, quality and character using apprc^riate scales prior to the Intervention. The Pain Assessment section oftiie fbrm for evening shift shows a pain rating of "Q/1 0." The sections labelled "quality", "pattern", and "reassessment" were bfank. Surveyor #3 found no evidence a pain managomont plan had been developed or acceptable levels of pain had been established with the patient as directed by hospital policy. 3. At the time of the medical review. Staff #2 confirmed the findings. When asked by the StErto Fonn 2S67 STATE FORM e je 7 ii EcerUkkuilsonahMl 7a(1 5 SPECIAL REQUEST 2018-130235 PAGE 272 PRINTED; 1 1 /2^/201 7 FORM APPROVED Stata of Washington STATEMEf^OF DEFICIENCIES AND PLAN OF CORRECmON (Xlt PROVIOEIVSUPaiER«LlA IDENTIFICATION NUMBER CASCADE BEHAVIORAL HOSPITAL L31 S (X^ DATE SUAIEY COMPLETED 11/02/2017 STREETMSOREGS, CITY, STATE, ZIP CODE 1 2844 MILITARY ROAD SOUTH TUKWILA, WA 981 68 , SUMMARY STATEMENT OP DEFICIENCIES (EACH DERCIENCY MUST BE PRECEDED BY FULL REGULATORY OR L8C IDENnFYINQ INrORMAPCH) P(4JID PREFIX TAG A. BUILDING: a WING. 604291 97 NAME OF PROVIDER OR SUPPUER (XZ) MULTIPLE CONSTRUCTION Continued From page 7 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTTON SHOULD BE CR08S-REFEHENCEDT0 THE APPROPRV>iTE DEFICIENCY) ID PREFIX TAG DU) COMPLETE DATB L31 5 Surveyor about Feassessiriont time frames and how effectiveness of the Intervention was detemiined, Staff #2 staM (hatreassessments were to be completed within 1 5 to 30 minutes and reassessment for effectiveness should include a pain rating. 4. At the time of the medical record review, the Director of Clinical Service (Staff #4) stated that reassessments were to be completed wthin one hour and stated that the fbmi did not provide a space for reassessment documentation and times. 5. Review of (he psychiatnc hospitafs policy showed that the poScy felled to provide guidance on reassessment content and timeframes. 6. Similar findings were found In the medical records for patients #3, #4 and #5. L7 1 0 322-1 00.1 D INFECT CONTROL-PHYS ENVIRON L71 0 WAG 246-322-1 00 Infection Control. The licensee shall: (1 ) Establish and Implement an effective hospital-wide Infection control program, which Includes at a minimum: (e) A procedure to monitor the physical environment of the hospital for situations which may contribute to the ^iread of Infectious diseases; This Washington Administrative Code Is not met as esndenced by: Based on observation and Interview, the psychiatric hosfxtal staff felled to maintain appropriate disinfectant levels In housekeeping Stata Fomi 2567 STATE FORM 8Jam aoontHuBlionchset SoT IB SPECIAL REQUEST 2018-130235 PAGE 273 PRINTED: 11/27/2017 FORM APPROVED state of Vteshinaton STATEMENT OF DEFICENaES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUERA»JA IDENTIHCATION NUMBER: (X2) UULT1PLG CONSTRUCTION A. BUILDING: B.WING. 6(M291 97 1 1 /02/201 7 NAME OF PROVIDER ORSUPPUER STREET ADDRESS. CD Y, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 1 2844 MILITARY ROAD SOUTH TVKWILA.WA 981 68 SUMMARY STATEMENT OF DEFICIENCIES (EACH D^IOENCY MUST BE PRECEDED EfY FULL REGULATORY OR LSC IDENTIFYING INFORMAnOM) OU)iD PREFIX TAG (X3) DATE SURVEY COMPLETED L71 0 Continued Froni page 8 PROVIDERS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD DE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAG L71 0* 0(5} COMPLETE DAIB L710 332M00.1 D INFECT C0NTR0L-PHY8 ENVIRONMENT carts. Failure to maintain the ieveia of dlslnfactant solution in housekeeping carts puts patients, staff and visitors at risk of exposure to infectious organisms. Findings Inciucled: I . O n 1 0/31 /1 7 at 9:30 AM, SuTveyor#2 useda chemical test strip to assess the quantity of active disinfectant in the sanitation bucket located on a housekeeping cart on Unit 4 Wbst. The observation showed that the bucket had <1 00 ppm (parts per miiiion) of concentrated disinfectant, less than the 600 ppmdescribed by the product msnufacturer. 2. On 1 1 /2/1 7 between 1 0:00 and 1 0:1 5 AM, Surveyor #2, accompanied by the housekeeping supervisor (Stiff #5), used a chemical test strip to assess the quintlty ofactive disinfectant in the sanitation bucket located on a housekeeping cart on the 2nd floor. The observation showed that the bucket had <1 00 ppm of concentrated disinfectant, less than the 600 ppm described by the product manufacturer. The surveyor then used a chemical test strip to assess the concentration of disinfectant produced from the dispenser In the housekeeping closet. Tho indicator showed the concentration coming from the dispenser was at the correct concentration. 3. At the time Of the observation listed In (#2) the surveyor asked Staff #5 If she used any test strips to periodicaily chock the concentration of the product used in the housekeeping carts. She Indicated that she did not The concentration of product in water is dependent on water temperatuiB and hardness, and may not stay State Form 2567 STATE FORM HOW: All housekeeping staff MIII be educated to the requiiemenls and processes te maintain ' appropriate levels ofdtslnfeclanl solutions as defined by the product manufacbirer. WHOiHousekeeping Manager WHA'H The Housekeeping manager or designoo will be responsible for ensuring that all disinfectant solutions are mMnfdned at the appropriate levels i)y houskeeping staff. The h ousekeeping manager or desgnee wUl audit dlainfedanl aolutiorts used for daantng at the beginning of each shift. Audit results wiD bo raported monthly to Performance Improvement Committee and quarterly to MEG and Governing Board. Monthly audils will continue until 1 00 percent compliance can be maintained for a period or two consecutive monlha, after wNch a quarterly audit will be conducted. WHEN: All conrecUve actions wiD be compleled by 02-01 -201 8 9J6711 tfeanUnuoUonrfMM 90(16 SPECIAL REQUEST 2018-130235 PAGE 274 PRINTED; ^MZlJ20^7 FORM APPROVED STATEMEm' OF DEFICIENCIES AND PLAN OF CORRECriON P(1) PROVIDER/SUPPLIER/CLIA IDENnRCAnON NUMBER: pcq MULTIPLE CONSTRUCTION A niJILniNR; B. WING 604291 97 1 1 /02/201 7 NAME OF PROVIDER ON SUPPUOr STREErADORESS.CrTY, STATE. 2IP CODE CASCADE BEHAVIORAL HOSPrrAL 1 2844 MILITARY ROAD SOUTH TUKV.ILA. »A S.1 .8 SUMMARY STATEMENT OF DEFICIENOES (EACH DEPICIENCyMUST BE PRECEDED BY FULL REGUiATORYOR LSC IDENTIFYING INFORMARON) PM)ID PRERX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVEACTION SHOULDBE CROSeREFERENCCD TO THE APPROPRIATE DEFiaENCY) ID PREFIX TAG 1 985 PCS) OOMPLfTE DATE LSaS 322-1 50.3B EXAM ROOM-UQHT HOW: An examination nghtvulD be procuredand placed In Ihe examination room located In 2 North. 322-1 50.3D EXAM ROOM-UGHT L985 (X3) DATE SURVEY COMPLETED WHOiDlrector or Facilities WAC 24&322-1 S0 Clinical facilities. The licensee shall provide: (3) One or more physical examination rooms, with or without an exterior window, equipped \Mth: (b] Examination light; This Washington Administrative Code is not m et' as evidenced by: tVHAT: An examhah'on light wil boprocured and placed In the examination room located In 2 North. The presence of the light will be audited through the annual blo-medlca] certiflcallon process. WHEN: AH oorrscUva actions wW be cornpieled by 01-03-201 8 Based on observation and interview, the psychiatric hospital failed to provide a dedicated exam room containing an examination light for patient exams. Failure to have an examination room that compiles with the state licensing requirement puts patients at risk from ineffective or substandard medical care. Findings included: 1 . On 1 0/31 /1 7 at 1 1 :00 AM, Surveyor #2 observed a room set up for physical exams on 2 North, behind a door signed "clean utility". The room contained an exam table, locked cabinets with patient care supplies, a hand wash sink, but (he room was not equipped with an exam light. 2. At the time of the observation, the facilities supervisor (Staff #6) conftnned the finding and indicated t i m was no other room In the building set up for physical examination L114S 322-1 80.1 C RESTRAINT OBSERVATIONS Stats Form 2567 STATE FORM L1 1 45 8je7ii VconlhuallanBhMl 1 0of1 6 SPECIAL REQUEST 2018-130235 PAGE 275 PRihfTED: 1 1 /27/201 7 FORM APPROVED state of Vteahlnoton 6TATEMENT OF DEFICIENCieS AND PLAN OF CORRECTION PROVIDER/SUPPUERiCUA IDENTIFICATION NUMBER: (K2) MULOPLE CONSTRUCTION A DUILDINO: B.VVING. 604291 97 1 1 /02/201 7 NAME OF PROVIDER OR SUPPUER STREET ADDRESS, CITY, STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 1 2644 MILtTARy ROAD SOUTH TUKVnLA.WA 981 68 (X4)ID PREFIX TAQ 0(a> DATE SURVEY COMPLETED SUMMARY STATEMENT OF DEFICIENCIES (EACH DEPICIGNCY MUST DE PRECEDED BY PULL REGULATORY OR LSC IDENTIFYING INFORMATION) L1 14S 322-1 80.1 C RESTRAINT OBSERVATIONS PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) ID PREFIX TAQ L1 1 45 (X6) COMPLETE tWTE L1 1 46 322-1 80.1 C RESTRAINT OBSERVATIONS Continued From page 1 0 WAG 24&-322-1 80 Petient Safety and Seclusion Care. (1 ) The licensee shall assure seclusion and restraint are used only to the extent and duration necessary to ensure the safety of patients, staff, and property, asfbllows; (c) Staff shall obswve any patient In restraint or seclusion at least every fiReen minutes, intervening as necessary, and recording observations arxf interventions In the cllnlcal record; This VUbshlngtonAdminisfratiVB Code Is not met as evidenced by: Based on Interview and review of medical reccrdSi the psychiatric hospital failed to monitor patients in restraints eccording to its policy fbr 2 of 3 patients reviewed (Patients #6. #7, and #8). Failure to follow established restraint policies and procedures places patients at risk of % sical and psychological harm related to inapprc^rlate restraint/sociusicn or Inadequate assessments before and during restraint/secluston episodes. HOW: A* Sta ff were educated In a staff meeting for aH nursing staff on/b^ween 1 2.1 S-1 2.^.1 7 to the Importance of the "Restraint and Sedualon Rowsheel," and that skin and dreulation checks must be completed every 1 5 minutes by a Registered Nurse. WHO:Chlef Nursing Officer (CNO) WHAT: The CNO or designee will be responsible for ensurtrrg that a l patients place In restraint have appropriate circulation chocks completed as required per policy and procedure. The CNO or designee will audit ail "Restraint and Seclusion Flowsheets". Audit results vulD be reported monthly to Performance Infuovement ComrnlUee and quarterly to MEC and Govemtng Board. Monthly oudtla will conUnuo until 1 00 percent compliance can be maintained for a period of two consecutive months, after which a quarterly audi! will be condudod. Each episode of restreint is audited by supervisor or Director fbr Immediate correction of behavior/documentation. WHEN: All corrective actions vifti be completed by 01 -03-201 6 Findings included: 1 . The psychiatric hospital's policy and procedure titled, "Seclusion and Physical and Mechanical Restraint," Policy# PC.R.1 00 reviewed 01 /1 7, showed that patients in restraints must have circulation checks completed every 1 5 minutes. 2. The hospital's "Restraint and Seclu sion Flowsheet," revised 08/22/1 7, showed that skin and circulation checks are to be completed every I S minutes bv a Registered Nurse. Slate Fonn 2567 STATE FORM eJ8711 HDonllnuBllonahoot l l o l i S SPECIAL REQUEST 2018-130235 PAGE 276 PRINTED: 1 1 /27/201 7 FORM APPROVED' S tale of Washington $mraiyieKr OF oEnciENCiES AND PLAN OF CORRECTION ^1 } PR0ViDEIV8UPPLIERXU.IA IDENRFICATION NUMBER CASCADE BEHAVIORAL HOSPITAL (XS) DATE SURVEY COMPLETED 1 1 /02/201 7 STREET ADDRESS, CITY, STATE, ZIP CODE 1 2644 HIIUTARV ROAD SOUTH TUKWILA, WA 961 66 SUMMARY STATEMENT OF DCFICIENCES (EACH DERCENCY MUST BE PRECEDED BY FUU REGULATORY OR LSCIDENT1 FYINQ INFORMATION) OM)© PREFIX TAG A. BUILDING; aWING. 604291 97 NAME OF PROVEER OR SUPPLIER (X2) MULTIPLE CONSTRUCTION L1 145 Continued From page 11 PROVIDQYS PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCB) TO THE APPROPRIATE DEFICJENCY) ID PREFIX TAG PU) COMPLETE DATE L1 1 45 3. On 11/01/17, Surveyor #3 reviewed the medical record of Patient #7 for 5 episodes of behavioral restraint as follows: a. On 09/00/1 7 at 2:00 PM and roieased from restraint on 09/09/1 7 at 9:30 PM. b. On 09/1 1 /1 7 at 1:00 PM and released from restraint on 09/1 1 /1 7 at 5:00 PM. c. On 09/1 2/1 7 at 3:05 PM and releesed from restraint on 09/1 2/1 7 at 4:50 PM. d. On 09/1 3/1 7 at 9:45 AM and released from restraint on 09/1 3/1 7 at 9:45 PM. e. On 09/14/17 at 3:00 AM and released from restraint on 09/1 4/1 7 at 2:00 PM. 4. The review showed no documentation on the seclusion/restraint monitoring flowsheet to Indicate that staff members assessed the patient's circulation and respiration for the following periods: a. On 09/09/1 7 from 2:00 PM through 2:30 PM a period of 30 minutes. b. On 09/09/1 7 from 2:45 PM through4.i5 PM a period of 1 hour and 30 minutes. c. On 09/09/1 7 from 8:30 PM through 9:30 PM a period of 1 hour. d. On 09/1 1 /1 7 from 1 ;1 5 PM through 6:00 PM a parlod of 3 hours and 45 minutes. e. On 09/1 2/1 7 from 1 :45 PM through 2:45 PM a period of 1 hour. 6. The review showed that Certified Nursing Assistanis (CNAs) completed the ciimlalion checks that were documented in the medical record. The Intervention protocol indicates that Registered Nurses should complete the checks. 6. Review of the medical recofd tor Patient #9 showed similar findings. StaWFonn 2567 STATE FORM BJ871 1 ircortlnuBilan sheet 1 2 of 1 5 SPECIAL REQUEST 2018-130235 PAGE 277 state of Vteshlnaton S770EMEKT OF DERCIENCIES AND PLAN OF CORRECTION PRIMTED: 11/27/2017 FORM APPROVED 0(1) PROVIOER/SUPPUEfVCUA lOENnFICATION NUMBBI: 0(2) IAJLTIPI.E CONSTRUCTION A BULDINO: B. MNO 604291 97 1 1 /02/201 7 NAME or PROVIDER OR SUPPUER STREET ADDRESB, CITY. STATE, ZIP CODE CASCADE BEHAVIORAL HOSPITAL 1 2644 MILITARY ROAD SOUTH TUKWILA, WA 9816 8 SUMMARY STATEMENT OF OEFICIENCIES (EACH DEFiaENCY MUST BE PRECEDED BY FULL REGULATORY OR L6C IDENflFYlNG INFORMATION) 1X4) ID PREFIX TAG 0(3) DATE SURVEY COMPLETED L1145 Continued From page 1 2 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSSREFERENCED TO THEAPPROPRIATE DEHCIENCY} ID PREFIX TAG (Xfl) CCMPLCTE DATE L1 1 45 7. On 1 1 /02/1 7 at 1 1 :30 AM, Surveyor #3 Interviewed the Chief Nursing OfRcer (S taf #3). She stated the psychiatric hospital was aware the current "Restraint and Seclusion Flowsheet." showed that skin and circulation checks were to be compteted every 1 5 minutes by a Registered Nurse. She stated that the format of the form may be creating confusion related to who has responsibility. She also stated that the hospital was In the process of developing improved documentation forms and the every 1 5 minute circulation checks will be com plete by tfie staff member providing the continuous in-person monitoring. L1425 322-21 0.4B MED P&P-ADVISORY GROUP WAC 246-322-21 0 Pharmacy and Medication Services. The licensee shall: (4) The appr(Y)riate professional staff committee shall approve all poiides and procedures on drugs, after documented consultation with: (b) An advisory group comprisod of representatives Iram the professional staff, hospital administration, and nursing services; This Washington Administrative Code Is not met as evidenced by: L1425 L1 426 322-21 0,48 MED PftP^DVISORY GROUP HOW: Emergen^ Medications, Poll^#PHR 1 32 vufll be updated to reflect the current medication storage practice artd Inventory. WHO: Pharmacist in Charge (PIG) WHAT: The f^iarmaclst In Charge (PIC) or designee will be responsible for ^suiing that Policy #PHR 1 32 is updated to reflect the current emergency medication inventory and storage practices at (facade Behavioral Hosfdtai. This policy will be approved by the Medical Staff In coorAnatlonwilh Iho Pharmacy and Therapeutics CommiUee (P&T). WHEN: All corrective actions wDI be oompieted by 01 -03-201 8. Based on observation, Interview, and review of the psychiatric hospital policies and procedures, the hospital failed to fbllow its policy and procedure for review and selection of emergency medications and emergency medication storage. Failure to follow established ho^ital policy and State pciin 2667 STATE FORM 9J871 1 KconlinuatonBhoiit laoTI S SPECIAL REQUEST 2018-130235 PAGE 278 PRUNED; 1 1 /27/^1 7 FORM APPROVED* State Of Vteshinaton STATEMENT OF DERCIENCIES AND PLAN OF CORRECTION (XI) PROVIDER/SUPPUERAXIA IDENTIFICAnON NUMBER: CASCADE BEHAVIORAL HOSPITAL L1 426 {X3) DATE SURVEY COMPLETED 1 1 /02/201 7 STREET ADDRESS, CITY, STATE, a p CODE 1 2844 MILHARY ROAD SOUTH TUKWILA, WA BB168 SUMMARY STATEMENT OF DB'ICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (XDID PREFIX TAG A. BUILDING! B.MNO. 60429197 NAME OF PROVIDER OR SUPPLIER