(xl) provider/supplier/clia identircatlon number: 60429197 (x2) multiple construction a. building:...

State of WashingtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(Xl) PROViDER/SUPPLIER/CLIAIDENTiRCATlON NUMBER:

60429197

(X2) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WINS,

PRINTED: 06/16/2020FORM APPROVED

(X3) DATE SURVEYCOMPLETED

c06/02/2020

NAME Of-' PROVIDEROR SUPPLIER STREET ADDRESS, OTY, STATE, ZIP CODE

12844 MILITARY ROAD SOUTHCASCADE BEHAVIORAL HOSPITAL

TUKWILA,WA 98168

(X-)} (DPREFIX

TAG

LOGO;

L670!

SUMMARY STATEMENT OF DEFICiENClES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

INITIAL COMMENTS

STATE COMPLAINTINVESTIGATiON

The Washington State Department of Health(DOH) in accordance with WashingtonAdministrative Code (WAC), Chapter246-322Private Psychiatric and Alcoholism Hospitals,conducted this complaint investigation.

investigation dates: 05/13/20 -06/02/20

intake number: #100399

Examination number: 2020-6632

The investigation was conducted by;

Investigator #42599

There were violations found pertinent to thiscomplaint.

322-050.12G RECORDS-PERFORM EVALS

WAG 246-322-050 Staff. The licenseeshall: (12) Maintain a record on the

iDPREFIX

TAG

LOGO

L 670

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRSATEDEFiCiENCV)

1. A written PLAN OF CORRECTION isrequired for each deficiency listed on theStatement of Deficiencies.

2. EACH plan of correction statementmust include the following:

* The regulation number and/or the tagnumber;

* HOW the deficiency wi!i be corrected;

* WHO is responsible for making thecorrection;

* WHAT will be done to preventreoccurrence and how you will monitorfor

continued compliance; and

* WHEN the correction will be completed.

3. Your PLAN OF CORRECTION mustbereturned within 10 calendar days from thedate you receive the Statement ofDeficiencies. PLAN OF CORRECTIONDUE: June 26. 2020.

4. The Administrator orRepresentative'ssignature is required on the first page ofthe original.

5. Return the original report with therequired signatures.

{?)COMPLETE

DATE

State Form 2567LABORATORY DIRECTOR'S OR PRQVfDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

^ 7^^ Zo^STATE FORM 76FW11 if conlinualion shsel 1 of 8

PL^L ^- C€^^Û^C^^-^- ^Mô PU^^ ^WÛn^^pp^^ 0^1^ Tio\^



(Xl) PROVIDER/SUPPUER/CLIA)DENTIRCAT!ON NUMBER:

60429197

(X2) MULTiPLE COMSTRUCTION

A. BUILDING:

B. WIMG


c06/02/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE.ZIPCODE

12844 MILITARY ROAD SOUTHCASCADE BEHAVfORAL HOSPITAL

TUKWiLA,

(X4) IDPREFIX

TAG

L 6701

itaie Form 2567

SUMMARY STATEMENT OF DEFiCiENCIES(EACH DEHCIENCy MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATiON)

Continued From page 1

hospital premises for each staffperson, during employment and for two

years following termination ofemployment, induding, but not limitedto: (g) Annual performanceevaluations.

This Washington Administrative Code is not metas evidenced by:

Based on record review and interview, the

hospital failed to develop an effective process toensure annual performance evaluations were

conducted and records retained for 4 of 6 staffmembers reviewed (Staff #1, #3. ff 7, and #8.)

Failure to conduct annual performance

evaluations limits the hospitai's ability fo ensurethat staff members are satisfactorily performingrequired job duties.

Findings included:

1. Record review of the hospital policy titled,"Performance Evaluation Process," policynumber

HR.PE.140, revised 01/20, showed that hospitalemployees receive performance evaluations

following 90 days of initia! employment and thenannually, either on the anniversary date or a

facility wide review date established bymanagement.

2. On 06/01/20 at 1;00 PM, the investigatorconducted a video interview with the HumanResources Director (Staff #6), the Chief NursingOfficer (Staff #9), and the Director of Risk andQuality (Staff #5). Record review of the personneitiies showed that;

a. Aregistered nurse (Staff #1) received his mostrecent performance evaluation on 01/31/19.

T_

VA 98168

IDPREFIX

TAG

L 670

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVEACTION SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY}

•AG L670

tZZ-050.1ZG RECORDS-PERFROMANCE EVALS

iOW.

'he Hospltsi's Human Resource Director w! II change

he HR policy to reflect; 1) the facility will utilize atat!c (fixed) date, annual job performance

'valuation date for afl employees. We wi!! move

iway from a roiilng caiendar performance

issessment due date on the empioyee's hire date.

'his will a!low for easier auditing and establish a

:ommon comptetion date amongst a!! managers.

Vho:

\[\ Ciinicai Managers will ImplemenE this static (fixed)|

fate performance evaiuatlon process. This will

insure that the performance evaluations are

:omp!eted annualiy on a reoccurring, non-changing

mnua! date.

A/hen:

Prior to 08/01/2020/ the W policy will be changed:o reflect a static (fixed) date annual performance

ivaiuatlon date for all employees/ moving away from}

:he performance evaluation due date based on the

imployee s hire date,

Prior to 08/01/2020, aEI annual performance

ivaluations will be obtained, reviewed with the

>mp!oyee, signed, and placed within the employees

luman resources fi!e.

A/hat:

•Clinical managers will ensure; 1) that their

employees performance evaluations are completed,

(X5)COMPLETE

DATE

STATE FORM 76FW11 IfcontinuaUon sheQl 2 of 8

State of Washington


'eviewed with the employee, signed by the

smployee, and a copy placed within the employee's

;human resources file every year by the due date.

lEvaluatlon tVtethod;

-The Human Resource Director will monitor for

[compSlance, beginning with data collection In August

i2020.

-On a monthly basis, the Human Resource Director

[will report compliance through the Quality Counct!

IScorecard.

!GOAL= 95%

Sfate Form 2567STATE FORM 76FW11 Ifconlinualion sheet 3 of 8

PRINTED; 06/16/2020FORM APPROVED


(X1) PROVIDER/SUPPUER/CUAJDENTiFICATION NUMBER;

60429197


A. BUILDING:,

B. WING


G06/02/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE.ZIPCODE

12844 MiLITARY ROAD SOUTHCASCADE BEHAVIORAL HOSPITAL

TUKWILA,

(X4) fDPREFIX

TAG

L 670}

LI 290^

SUMMARY STATEMENT OF DEFICIENCSE8(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)


b. A mental heaiih technician (Staff #3) receivedher most recent performance evaluation on

11/19/18.

c. A menta! health technician (Staff #7) receivedher most recent performance evaluation on

03/29/17.

d. Asociat worker (Staff #8) received his mostrecent performance evaluation on 3/29/19.

3. On 06/01/20 at 4:06 PM Staff #5 confirmed viaemail that the identified staff members did nothave annual performance evaluations conductedinlhe past 12 months.

322-200.3K RECORDS-NURSE SERVICES

WAG 246-322-200 Clinical Records. (3)The licensee shall ensure prompt entryand tiling of the following daia intothe dinical record for each period apatient receives inpatient oroutpatient services: (k) Nursingservices;

This Washington Administrative Code is not metas evidenced by:

Based on interview and document review, the

hospital failed to include nursing documentationof nursing assessments and progress notes in

the medical record for 2 of 2 patient recordsreviewed (Patients #1 and #2.)

Failure to have complete medical records thatcontain all patient information risks unsafe caredue to lack of complete, accurate, and timely

/A 98168

IDPREFIX

TAG

L 670

L1290

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVEACTIOM SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)

•AG 11290

t22-200.3K RECORDS-NURSING SERVICES

\ow. Nursing services personnel (RNs) will be

eeducated regarding the policy related to the

:ompletion of nursing assessments, incident

eporting, assessment of risk pertaining to sexual

violence, and daily nursing progress notes. Relevant

:ritical clinical information wil! be communicated .

iuring mid-shift safety huddles, and documented

vlthinthe huddle book communication.

/Vho:

'he Chief Nursing Officer with the assistance of the

^lurse Managers, will ensure that aii nursing services

personnel (RNs) wili receive this

'ducation/retraining. Nurse managers In conjunctlor

with the charge nurses will ensure that the critical

:!inicai Information is communicated during the mid-

(X5)COMPLETE

DATE

State Form 2587

STATE FORM 76FW11 If continuation sheat A oF 8

State ofWashincjtpn

PRINTED; 06/16/2020FORM APPROVED

tshlfE safety huddles and documented within the

huddle book communication.

iWhen;

[-Prior to 08/01/2020, the Chief Nursing Officer will

insure that ail education/retralning has occurred-

jwith documented evidence in the personnei fifes.

hPrior to 08/01/2020, emphasized education

[regarding completion of nursing assessments,

incident reports, assessments of risk pertaining to

|sexua! violence towards others, and daily progress

^notes will be stressed In new employee orientation,

[added to the orientation checklist, and completed in

|i:he annua! nursing skills fair.

J-Prior to 08/01/2020, nurse managers and nursing

{supervisors wi!i observe the mid-shift safety buddies

jand huddle book communications daily.

EWhat:

1-Chief Nursing Officer in conjunction with the Nurse

[Managers wit! ensure: 1) That education regarding

Scompletton of nursing assessments, incident reports,

Jassessments of risk pertaining to sexua! violence

{towards others, and daily progress notes will be

[stressed in new employee orientation, added to the

[orientation checklist, and compieted in the annual

Inursing skills fair,

[Evaluation Method:

prhe charge nurse during the treatment team

jmeeting will review the charts daily/ to ensure the

[documentation is present. If it is not, they wi!l notify I

[nursing administration immediately.

-On a monthly basis, nursing administration will audit}

|30 charts and report those findings through the

[Qua!lty Council Scorecard.

iGOAl= 90%

Stale Form 2567

STATE FORM 76FW11 !(continualion sheet 5 of 8


State of WashinfltonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDERfSUPPLIER/CUAiDENTIFICATION NUMBER;

60429197

(XZ) MULTIPLE CONSTRUCTION

A. BUILDING:

B. WING,


c06/02/2020

NAME OF PROVJDEROR SUPPLIER

CASCADE BEHAVfORAL HOSPITAL

STREET ADDRESS. CiTY, STATE, Z!P CODE

12844 MIUTARY ROAD SOUTH

TUKWILA.WA 98168

(X4} IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICSENCIES(EACH DEFiCIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)

IDPREFiX

TAG

PROVIDER'S PLAN OF CORRECWN(EACH CORRECTIVE ACTiON SHOULD BE


(X5)COMPLETE

DATE

U 290 Continued From page 3

Findings included:

1. Document review of the hospital policy titled,"Incident Reporting," Policy #RM.200, revised01/20, showed that when incidents involvingpatients occur at the hospital, staff mustdocument relevant information including preciselywhat happened, in the patient's medical record.

Document review of hospital policy titled, "SexuaiSafely Precautions," Policy #CS.SSP.101.approved 09/25/19, showed that on admissionand throughout hospitaiization, all patients will beassessed for risk of sexual violence toward

others using the "Sexual Acting Out RiskAssessment" form.

Document review of the hospital policy titled,"Assessment/Re-Assessment," Policy

#PC.A,700, reviewed 02/20, showed that aregistered nurse (RN) will perform acomprehensive nursing assessment on all

patients within 8 hours of admission to thehospital.

2. Review of facility incidents showed that on04/10/20 at 12:15 PM, Patient #2 was observedentering the room of Patient #1, The reportshowed that the staff member immediately calledfor heip and rushed into Patient #1 's room.Patient #2 was instructed to leave the room, buthe initially refused to ieave. He was escorted

back to his own room by two staff members,Patient #1 was observed looking fearful as shestood in front of Patient #2. Patient #1 told staffthat Patient #2 touched her on the breast and onher private area.

3, Document review of patient medical records

U 290

State Form 2567STATE FORM 78FW11 If continuation sheoi 6 of 8


State of WashingtonSTATEMENT OF DEHCIENCfESAND PLAN OF CORRECTION

(X1) PROVIDER/SUPPUER/CUAIDENTIFICATION NUMBER:

60429137

(X2) MULTIPLE CONSTRUCT!ON

A. BUILDING:

B. WiHG,

(X3) DATE SURVEYCOMPIBTED

c06/02/2020

NAME OF PROVIDER OR SUPPLIER

CASCADE BEHAVIORAL HOSPITAL

STREET ADDRESS. OTY, STATE. Z!P CODE

12844 MIUTARY ROAD SOUTH

TUKWILA,WA 98168

(X4) IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC iDENTIFYSNG INFORMATION)

!DPREFIX

TAG



W}COMPLETE

DATE

L1290 Continued From page 4

showed that:

a. Patient #1 was admitted to the facility foropioid addiction treatment on 02/26/20. Whilehospitalized, Patient #1 became delusiona! andpsychotic, and on 03/20/20, a court order forinvoluntary detainnrsentwas received, and she

was transferred to the acute inpatient psychiatricunit on 3W, A social work progress note dated04/10/20 at 3:30PM, showed that on 04/10/20,Patient #1 was transferred to 2N following an"incident on 3W," and the patient reported feeling"okay" and "lucky it didn't go further." Medicalrecord review showed no evidence of

documentalion that Patient #1 was the victim ofan alleged sexual assault on 04/10/20. Review ofPatient #1's medica! record showed that all ofthenursing reassessment and progress note

documents for 04/10/20 were missing.

b. Record review showed that Patient #2 arrivedto the facility on 04/03/20 at 09:15 AM, and at3:00 PM, nursing staff documented that since hisarrival that day, Patient #2 had stripped nakedmultiple times, repeatedly made sexuallyinappropriate comments to staff, attempted totouch female staff members in a sexual manner,

and on one occasion disrobed and grabbed ontoa female staff member until other staff membersphysically intervened. Review of the medicalrecord showed that staff failed to perform aSexual Acting Out (SAG) Risk Assessment within8 hours of admission according to hospital policy.

4. On 05/28/20 at 1 0:30 AM Staff #1, a registerednurse, was interviewed. Sfaff#1 stated that whenincidents involving patients and staff occur in thehospital, staff complete an incident report, write aprogress note in the patient's chart, and discussthe incident with the supervisor. Staff #1 stated

U 290

State Form 2567STATE FORM 76FW11 If continualion sheet 7 of 8


State ofWashincitonSTATEMENT OF DEFICIENCIESAMD PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIEFyCLIAIDENTiFlCATION NUMBER:

60429197


A. BUILDING: _.„

B. WING


c06/02/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CiPf', STATE.ZIPCODE

12844 1VIILITARY ROAD SOUTHCASCADE BEHAVIORAL HOSPITAL

TUKWILA,

(X^) IDPREFIX

TAG

L1290 I

U30i

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC (OENTJFYING JNFORMATfON)


(hat when a patient is admitted to the facility, theadmit nurse completes the admission paperworkincluding the Sexual Acting Out (SAG) RiskAssessment, and Ihey notify the provider if thepatient requires orders for special precautions.

5. On 05/28/20 at 12:27 PM Staff #2, a registerednurse, was interviewed. Staff ^2 stated that whenincidents involving patients occur in the hospita!,staff complete an incident report and write aprogress note in the patient's chart. Staff #2stated that on 04/10/20, she completed a nursingreassessment and progress note for Patients 1h

and #2, but hospital staff were unabfe to locatethe nursing reassessments and progress notes

dated 04/10/20 in Patient #1's medical chart,

6. On 05/27/20 at 4:40 PM, the 3W NurseManager, StaH ff4, confirmed via email that thehospital was unabie to locate the -'1/10/20 nursingreassessments and progress notes for Patient

#1. Staff iM also stated that Patient #2 wasplaced on SAO precautions, but Staff #4 wasunabie to locate a SAG Risk Assessment form inPatient #2's medical record,

7. During a video conference interview on

06/01/20 at 1:00 PM, Staff #5, the Director of Riskand Quality, confirmed the investigator's findingsthat the hospital was unable to locate the 4/10/20nursing reassessments and progress notes for

Patient #1, hospital staff failed to document theincident of alleged sexual assault in Patient #1'smedicai record according to hospital policy, andhospital staff did not complete a SAG RiskAssessment for Patient #2.

322-200.4A RECORDS-DATE

/A 98160

IDPREFIX

TAG

L1290

L1305



(X5)COMPLETE

DATE

State Form 25S7

STATE FORM 76FW11 If continualion sheet 8 of 0


State of WashinfltonSTATEMENT OF DEFIOENCIESAND PLAN OF CORRECTION

(Xl) PROVIDER/SUPPLIEfVCUAIDENTIFICATION NUMBER:

G0429197

(X2) MULTiPLE CONSTRUCTION

A, BUiLDING:

8. WING


c06/02/2020

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. C!U', STATE. Z!P CODE

12844 MILITARY ROAD SOUTHCASCADE BEHAVIORAL HOSPITAL

TUKWI LA, WA 98168

(X4) IDPREFIX

TAG

U 3051

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFJCIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)


WAG 246-322-200 Clinical Records. (4)The Sicensee shgll ensure each entryincludes: (a) Date;: (b) Time of day; (c)Authentication by theindividual making the entry;

This Washington Administrative Code is not metas evidenced by;Based on interview, review of patient records and

review of hospital poiicies and procedures, thehospital failed lo ensure that all medical recordscontained accurate date entries for 2 of 2 medicalrecords reviewed (Patients #1 and #2).

Faifure to develop and maintain accurately datedmedical record entries risks inisinterpretation ofinformation.

Findings included:

1. Document review of the hospital poiicy titled,"Documentation Protocois," Policy #PC.L.300,

reviewed 02/20, showed that all medica! recordsare to be accurate, truthful, and complete. Policy

review showed that all medical record entries areto be confirmed by written signature, dates, times,and credentials.

2. Record review showed that:

a. Four patient observation records contained no

date(Palient#1).

b. Three patient observation records containedno date (Patient #2).

c. Patient #1 had two different patientobservation records for day shift and two differentobservation records for night shift dated 03/28/20,

10PREFIX

TAG

L1305

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTiVE ACTION SHOULD BE


[AG L1305

322-200. 4A RECORDS-DATE

How:

cursing services personnel will be reeducated

"egardlng the accurate dating of elements within the

Tiedicaf record, to include the observation records.

Elements within the patient's dinical record w![| be

'evtewed daily for accuracy.

i/Vho:

rhe Chief Nursing Officer with the assistance of the

\furse Managers, w]H ensure that all nursing services

personnel (RNs) will receive this

iducatlon/retraining. The charge nurse will be

'•esponsible for reviewing each chart daiiy.

A/hen;

•Prior to 08/01/2020/ the Chief Nursing Officer will

insure that all educatlon/retrainlng has occurred-

with documented evidence In the personnel f!!es.

Prior to 08/01/2020, accurate dating of nursing

•iements, including the observation records, wi!t be

:hecked daily by the charge nurse and treatment

team,

accurate dating of elements within the patient's

:linjcai record will be stressed in new employee

3rientat!on, added to the orientation checklist, and

:ompleted in the annual nursing skills fair.

A/hat:

(XS)COMPLETE

DATE

Slate Form 2567STATE FORM 76FW11 If continuation sheet 9 of 8


State of Washinflton-Clinical managers will ensure: 1) that the charge

|nurse is ensuring the correct date is reflected on the

jeiements within the patient record. Any

|discrepancies will be rectified if possible or reported

|to the nurse manager and Chief Nursing Officer.

.Evaluation [Vlethod;

-The charge nurse during the treatment team

|meet!ngwil! review the charts daily, to ensure the

^documentation Is present. If it is not, they will notify |

nursing administration immGctiately if it is absent.

-On a monthiy basis, nursing administration will auditj

|30 charts and report those findings through the

[Quality Council Scorecard.

[GOAL= 90%

State Form 2567STATE FORM 76FW11 if cortlinuation sheet 10 of


State ofWashinqtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CUAIDENTinCATiON NUMBER:

60429197

(X2) MULTIPLE CONSTRUCTiON

A. BUILDING:

B. WING.


c06/02/2020

NAME OF PROVIDER OR SUPPLIER

CASCADE BEHAVIORAL HOSPITAL

STREET ADDRESS. CR"Y. STATE, ZIP CODE

12844 MILITARY ROAD SOUTH

TUKW)LA,WA 98168

(X-)) IDPREFIX

TAG

SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFiCfENCY MUST BE PRECEDED BY FULLREGULVTORY OR LSC IDENTtFYiNG INFORMATION)

[DPREFIX

TAG

PROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTiON SHOULD BE

CROSS-REFERENCED TO THE APPROPRIATEDEFfCIEHCY)

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STATE OF WASHINGTON

DEPARTMENT OF HEALTHPO Box 47874 • Olympia, Washington 98504-7874

09/14/20

Soni Helmicki, Interim Director of Risk and QualityCascade Behavioral Hospital12844 Military Rd. S.Tukwila,WA98168

Re: Complaint #100399/2020-6632

Dear Ms. Helmicki,

I conducted a state hospital licensing complaint investigation at Cascade BehavioralHospital on 05/13/20 to 06/02/20. Hospital staff members developed a plan ofcorrection to correct deficiencies cited during this investigation. This plan of correctionwas approved on 06/30/20.

Hospital staff members sent a Progress Report dated 09/14/20 that indicates alldeficiencies have been corrected. The Department of Health accepts CascadeBehaviora! Hospital's attestation that it will correct all deficiencies cited at Chapter 246-322 WAC.

We sincerely appreciate your cooperation and hard work during the investigationprocess.

Sincerely,

,/^\y'

Coleen Barren, MBA, BSN, RNNurse Investigator

(xl) provider/supplier/clia identircatlon number: 60429197 (x2) multiple construction a. building:...

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