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Based on observation, interview, and document review, it was determined that the hospital failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body.

Failure to protect the patient's right to personal privacy resulted in loss of personal dignity, psychological harm and failure to ensure staff had the knowledge, skills, training, and equipment to respond to a patient's medical emergency resulting in treatment delay and inappropriate resuscitation measures.
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Findings included:

Due to the scope and severity of deficiencies detailed under 482.12(f)(2) Emergency Services and 42 CFR 482.13 Condition of Participation for Patient Rights, the Condition of Participation for Governing Body was NOT MET.


Cross-reference: Tag A-093 & Tag A-143.

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Item #1- Code Blue Response

Based on interview, document review, and review of policies and procedures, the hospital failed to ensure direct care staff took appropriate immediate actions to address an emergency resuscitation on a patient (Patient #903).
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Failure to ensure hospital staff had the required knowledge, skills, training and equipment to respond to a patient's medical emergency risks delays in activating and initiating urgent treatment.

Reference: Basic Life Support (BLS) Provider Manual, American Heart Association - 2016: Assess the patient to determine whether he or she is unresponsive. Tap the patient on the shoulder and shout, "Are you all right?" This helps ensure that you don't begin CPR on a conscious person. If the patient is unresponsive, shout for help and activate the emergency response system via mobile device (if appropriate) ... to make chest compressions as effective as possible the victim must be placed on a firm surface. If a patient is on a soft surface, such as a mattress, sufficient force cannot be achieved to allow compression of the chest and heart to create blood flow ... Equipment: Backboard or other firm surface, automated external defibrillator (AED). Optional: barrier mask with one-way valve, gloves, and other personal protective equipment.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Code Blue," policy #1000.13 reviewed 05/18, showed that staff members trained in cardiopulmonary resuscitation (CPR) will verify unresponsiveness and start CPR. The staff member is to direct the announcement of Code Blue (term used by hospitals to activate emergency response for patients requiring immediate resuscitation). Staff are to respond to the location with oxygen and code blue bag from each unit and the automated external defibrillator (AED). CPR is to continue until the AED arrives and is attached to the patient to analyze cardiac rhythms. The registered nurse (RN) with the most knowledge of the patient is to act as the Code Blue leader, directing other staff. The Code Blue is to continue until Emergency Medical Services (EMS) arrives and relieves the staff to care for the patient.

2. Review of the medical record and resuscitation (Code Blue) notes from 02/17/19 for Patient #903 showed:

a. Patient #903 was a 58-year-old patient admitted on 01/30/19 for schizophrenia and alcohol use disorder. The patient's history showed many medical comorbidities that included: hypertension, hyperlipidemia, coronary artery disease, venous stasis of lower extremities, asthma and morbid obesity.

b. Review of the psychiatrist progress note dated 02/17/19 at 12:00 PM, showed vital signs of blood pressure 120/51, pulse 89, temperature 97.9 degrees and respirations of 16.

c. On 02/17/19 at 5:30 PM, a staff member found Patient #903 in his room unresponsive and not breathing.

d. Document review of the Code Blue form showed that a staff member found the patient unresponsive in his bed at 5:30 PM, then additional staff were notified at 5:32 PM. The notes showed that no detectable pulse was found and that the patient was apneic (cessation of breathing), staff began chest compressions at 5:30 PM. The Code Blue form did not contain documentation addressing the patient's airway or if rescue breathing was provided. At 5:34 PM, the form showed chest compressions continued without addressing airway management or rescue breathing. At 5:34 PM, staff applied the AED to the patient's chest. At 5:40 PM, chest compressions continued without evidence rescue breathing was delivered. At that time the AED detected a nonshockable heart rhythm and did not advise a shock. Care was transferred to the arriving EMS crew at 5:40 PM.

e. A review of nursing resuscitation notes showed that EMS personnel continued chest compressions and rescue measures until 6:03 PM, then declared the patient deceased.

3. On 05/17/19 at 1:20 PM, Investigator #9 attempted to reach two staff nurses by telephone (Staff #902 and #903), present during Patient #903's resuscitation, but both attempts were unsuccessful. At 1:45 PM, Investigator #9 interviewed the Nurse Educator (Staff #904) regarding her review of Patient #903's resuscitation records and staff she interviewed, present during the Code Blue. Additionally, she reviewed video footage of the resuscitation. Staff #904 identified the following issues:

a. The staff member who found the unresponsive patient exited the room to call for help prior to initiating CPR.

b. A Code Blue Leader (a designated leader needed to direct and coordinate all components of the resuscitation) was not identified or designated.

c. Chest compressions performed on a non-firm surface (mattress) were ineffective and staff struggled to move the patient to the floor due to his large body size. Staff #904 noted the patient was moved to the floor using his bed mattress.

d. Backboards were not available during the resuscitation and were not included in the hospital's emergency equipment.

e. Staff had difficulty finding a handheld resuscitation bag and mask (a self-refilling bag-valve-mask unit, used for artificial respiration) in the Code Blue bag containing emergency equipment.

Item #2 - Emergency Equipment

Based on interview and document review, the hospital failed to ensure emergency equipment and supplies were available and accessible to staff during a critical medical emergency.

Failure to provide medical emergency equipment and supplies places patients at risk of inadequate resuscitation efforts that could lead to injury or death.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Code Blue," policy #1000.13 reviewed 05/18, showed that staff are to respond to the location with oxygen and code blue bag from each unit and the automated external defibrillator (AED).

The code blue bag inventory includes:

- Bandages and dressings.

- Airway management supplies: a CPR mask, ambu bag (a self-refilling bag-valve-mask unit, used for artificial respiration), plastic bite stick (used during seizures), nasal cannula and mask with tubing (for oxygen delivery).

- EMS supplies (sting swabs, alcohol prep pads, eyewash solution, ice packs, antimicrobial hand wipes, instant glucose, antibiotic ointment, iodine prep pads).

2. On 05/17/19 at 1:45 PM, Investigator #9 interviewed a Nurse Educator (Staff #904) about the Code Blue record. She stated that a back board was not used or available during Patient #903's resuscitation. Staff #904 stated that initially chest compressions were conducted while the patient was lying on his bed, atop a mattress. She noted the patient was moved to the floor, using the bed mattress and then the patient was moved directly onto the floor. A review of the Code Blue record did not include the time it took for staff to move the patient to the floor.

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Based on observation, interview, record review, and review of hospital policies and procedures, the hospital failed to protect the patient's right to personal privacy.

Failure to provide for privacy puts patients at risk for loss of personal dignity and psychological harm while performing personal hygiene and dressing activities

Findings included:

1. Failure to provide for privacy while performing personal hygiene and dressing activities.

2. Failure to provide personal privacy during physical skin assessments.

The cumulative effect of these systemic problems resulted in the hospital's inability to provide for 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: Tag A-143.
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Based on interview and record review, the hospital failed to provide a non-English speaking patient with an interpreter to translate and explain the "Patient Rights and Responsibilities" upon admission to the hospital (Patient #902).
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Failure to provide an interpreter to a non-English speaking patient to translate and explain their patient rights and responsibilities potentially places patients at risk for abuse, neglect or unmet care needs.
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Findings included:
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1. Document review of the hospital's policy titled, "Special Needs of Patients - Interpreter and Translator Services," policy # 1001.11 reviewed 08/23/18, showed that patients that are not fluent in English are offered the services of an interpreter by the admitting staff at no cost. The services are to be offered either through IN- Demand Interpreter machine, telephone or an on-site service based on patient's preference.
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2. Record review of Patient #902's medical record showed:

-the patient was a 60 year-old patient admitted involuntarily on 01/11/19 due to psychosis and an inability to care for herself.

-the patients primary language was Vietnamese. The patient did not speak English.

-the patient rights notification stated that the patient was unable to sign to acknowledge receipt of patient rights.

-There was no documentation in the medical record that showed that interpreter services were offered or used.

b. Additional document review showed that the licensed independent provider (LIP) did not complete the "Suicide Assessment Tool" on 01/12/19. She wrote on the Suicide Assessment Tool, "No records available and patient is unable to answer questions. Interpreter machine not working."
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3. At the time of the record review, Investigator #9 interviewed the nurse manager (Staff #901) about the apparent lack of interpreter services being offered to the patient. She stated that the admission staff should have offered interpreter services or documented if the patient had refused the interpreter services. She further stated that the LIP should have contacted an interpreter to be available by phone or in person if the interpreter machine was not working.

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Item #1 - Privacy Curtains

Based on observation, interview, and review of policies and procedures, the hospital failed to protect the patient's right to personal privacy.

Failure to provide for privacy puts patients at risk for loss of personal dignity and psychological harm while performing personal hygiene and dressing activities.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Patient Rights and Responsibilities," policy number 1800.1, effective date 12/18, showed that patients have a right to personal privacy. Care is rendered in a way that considers, respects, and protects the personal dignity of each patient.

2. On 05/15/19 at 9:50 AM, Investigator #3 and the Director of Nursing (Staff #301) toured the Child and Adolescent Unit. The investigator observed that there were no privacy curtains for the patient bathrooms in rooms #413 and #415. Without the bathroom privacy curtain, any staff or patient could observe any activity inside the room. Room 415 was assigned to 2 female patients. One of the 2 patients was identified as being on "sexual victimization precautions". In room 413, the male patient (Patient #301) was identified as being on "sexual assault precautions", and was subject to monitoring every 5 minutes because they had previously entered another patient's bathroom while the patient was toileting.

3. Following the observation, Investigator #3 interviewed the Director of Nursing (Staff #301) at 9:50 AM, about the absence of privacy curtains in the patient bathrooms. Staff #301 stated that the patients frequently pull down the curtains.

A Program Specialist (Staff #302), stated during an interview at 10:00 AM, that curtains are replaced once they are observed missing in the rooms.

Item #2- Skin Checks

Based on interview, review of recorded video footage, and review of policies and procedures, the hospital failed to implement and evaluate a standard admission skin check/search process that ensures a patient's right to personal privacy.

Failure to implement and evaluate a standard search process leads to inconsistent skin check practices that puts patients at risk for violating their right to personal privacy, risk of psychological harm and loss of personal dignity.

Findings included:

1. Record review of the hospital policy titled, "Patient Rights and Responsibilities," policy number 1800.1, effective 12/18, showed that patients have a right to personal privacy. Care is rendered in a way that considers, respects, and protects the personal dignity of each patient.

a. Review of the hospital's policy titled, "Skin Assessment," policy number 1001.40, revised 05/18, showed that upon arrival on the unit, the patient will go to a private area, remove their clothing in private and don a hospital gown. Once they are gowned, patients will go to a secondary area where a Registered Nurse (RN) will perform the skin assessment while another staff member will inspect the patient's clothing for contraband. After the check, the staff will return all allowed articles of clothing to the patient. At all times the patient's privacy and dignity will be respected.

2. On 05/14/19 between 09:50 and 11:20 AM, Investigator #4 interviewed seven (7) direct care staff about the admissions process at the Kirkland campus. Three (3) staff interviews (Staff #401, #402, #403) revealed the following:

a. The Investigator asked a Registered Nurse (RN) (Staff #401) in the South unit about the process for conducting initial skin checks and contraband searches for patients once they are admitted to the unit. The interview included questions about the number and types of staff who perform the skin checks, as well as where the exams take place. The RN stated that usually 2 staff members perform the initial check, but there have been times when only 1 staff person was available to conduct the skin check and search.

b. The Investigator asked a Program Specialist (Staff #402) in the East unit about the process for conducting initial skin checks and contraband searches for patients once they are admitted to the unit. The interview included questions about the number and types of staff who perform the skin checks, as well as where the exams take place. The staff member stated that staff perform skin checks in Room 505 (a seclusion room). The investigator observed that the seclusion room had a camera mounted on the wall near the ceiling. The staff member also stated that 2 people can do the skin checks, but 1 person can do it if it is a male staff member and a male patient.

c. The Investigator asked a Registered Nurse (RN) (Staff #403) in the East unit about the process for conducting initial skin checks and contraband searches for patients once they are admitted to the unit. The interview included questions about the number and types of staff who perform the skin checks, as well as where the exams take place. The staff member stated that she performed them alone due to lack of staff, unless the patient showed agitation. She stated that she had patients change into a gown or cover themselves with a blanket in the seclusion room bathroom, and then she performed the skin check in the seclusion room. The investigator asked about the camera surveillance in the seclusion room. The staff member stated that the camera is turned off unless a patient is in the room for seclusion.

Following the interview, the Investigator asked the unit's Program Manager (Staff #404) about the status of the camera in the seclusion room. The staff member stated that the cameras are always on, but no active monitoring occurs.

3. On 05/14/19 at 10:55 AM, Investigator #3 interviewed a Program Specialist (Staff #302) about the skin check and clothing search process done upon admission. Staff #302 stated part of the skin check process includes having the patient squat and then checking for any visible contraband. Staff #302 indicated the reason for having the patient squat was that some patients hide contraband.


4. On 05/15/19 at 2:00 PM, Investigator #10 interviewed a nurse (Staff #1004) assigned to the East Unit of the Kirkland Campus about how staff perform skin checks on the unit. Staff #1004 stated that all patients undergo a skin assessment performed by two nurses as part of the admission process. Staff #1004 confirmed that patients are escorted to the seclusion/quiet room and the initial skin assessment begins in a bathroom (no video camera) where patients are asked to remove all clothing. In the seclusion/quiet room (camera present), one nurse examines the entire skin for cuts, marks, tattoos, wounds, etc., and the second staff member searches the clothing for drugs or weapons. After a patient has completed their skin assessment and clothing search for contraband, then the patients can enter the unit and begin their treatment.

During a subsequent interview at 3:00 PM, the Director of Nursing (Staff #1005), stated that the video camera in the seclusion/quiet room, located in the East unit, is fully functioning. However, conducting skin checks in the unit's seclusion/quiet room is not their practice.

5. On 05/16/19 at 11:50 AM, Investigator #10 and the Risk Manager Coordinator (Staff #1006) reviewed a video recording of a patient's (Patient #1003) skin assessment performed on 05/09/19. A review of the footage showed a patient escorted to the seclusion/quiet room that contains an anteroom and a bathroom. Inside the bathroom (no camera present), the patient proceeded to undress himself while the bathroom door was wide open (to the anteroom), then staff handed him a gown to don. The video showed the patient and nurse enter the seclusion/quiet room (camera present), the location for the skin assessment. The seclusion room door was observed opened, when the nurse began examining the patient's hands, arms, chest and back, throughly. Review of the footage showed a second staff member looking through the open door, while leaving the main door (out to the unit) ajar, allowing other patients and staff to view the partially nude patient. The footage showed a third staff member walking in the room, then exit the room, only to return and leave the room again. The door remained opened (out to the unit) while the patient removed his underwear and shoes. During review of the footage, the investigator observed that during the exam you can see patients walk pass the open door, allowing individuals to see into the room. After the exam, the patient was given an orange scrub top, bottoms, socks, and shoes, then escorted out of the room(s).

Staff #1006 confirmed that the seclusion/quiet room door was opened to the main hallway during the patient's skin check.

6. On 05/14/19 between 8:50 AM and 12:45 PM, Investigator #10 interviewed seven (7) staff members who provide care to patients in the North Everett campus. Two staff (Staff #1001, Staff #1002) interviews revealed the following:

a. A staff member (Staff #1001) stated that all patients undergo a skin assessment performed by two nurses as part of the admission process. Staff #1001 stated that the skin assessment begins in a bathroom (no video camera) where patients are asked to remove all clothing and then taken to a secondary area, usually the seclusion/quiet room (video camera present). One nurse examines the patient's skin for cuts, marks, tattoos, wounds, etc., and the second staff member searches the clothing for drugs or weapons. When staff have completed their examination of the patient's clothing and their skin assessment, patients can enter the unit. However if a patient refuses a skin check/assessment, they are placed on a 1:1 observation until they complete the assessment.

Staff #1001 verbalized his understanding that the quiet/seclusion room is equipped with a video camera but is not sure if patients are informed of the camera's presence.

b. A staff member (Staff #1002) stated that new patients are escorted to the seclusion/quiet room, lead inside the adjacent bathroom (with the door ajar) where they fully undress and don a hospital gown. After they have donned a gown, staff escort the patient inside the seclusion/quiet room where an RN performs the patient's skin check by having the patient remove parts of the gown to expose the patient's skin.

Staff member #1002 stated that she will ask patients to squat to see if anything drops, but acknowledged that asking the patient to squat is not included in the hospital's policy.

Investigator #10 then asked the staff member if video recordings are conducted for the skin check. Staff #1002 stated that she was unsure if the video camera in the Seclusion/quiet room records the patient's assessment.

7. On 05/15/19 at 10:35 AM, Investigator #10 and the unit's Nurse Manager (Staff #1003) discussed video cameras in the unit. Staff #1003 stated that a video camera is present in the seclusion/quiet room and is constantly monitoring or functioning. The recording function turns on only when there is movement in the room, but video recordings are not available to staff to review. Video recordings are available for review by leadership staff, but for 30 days only.

After the interview, Staff #1003 provided a video recording of a patient's (Patient #1001) skin assessment performed on 05/11/19. A review of the footage showed the patient was escorted to the bathroom, adjacent to the seclusion/quiet room (inside the anteroom). The patient proceeded to undress herself while the bathroom door was wide open (to the anteroom), then staff handed her a gown to don. The video showed the patient and nurse enter the seclusion/quiet room. There the skin check began with the nurse examining the patient's hands, arms, head, chest and back. The nurse removed the patient's underwear and then took off the gown exposing the patient's body. The skin exam continued while the patient was standing in the room, fully undressed with the door opened to the anteroom, while another staff member walked in and out of the room. The video showed the anteroom door was closed to the unit's main hallway. After the exam, the patient was given an orange scrub top, bottoms, socks, and shoes, then escorted out of the room(s).

Staff #1003 stated that skin checks begin in a primary area (bathroom without camera) where patients fully undress, then don a hospital gown and taken to a secondary location (private area, outside of camera view) to perform the skin assessment. Staff #1003 added that the process may need to be reviewed and revised.

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Based on record review, interview, and document review, the hospital failed to modify the patients' plan of care after placing patients in restraints in 2 of 5 (Patients # 901 and #902) patient records reviewed.
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Failure to modify care plans when patients are in restraints, placed patients at risk of harm by not meeting physical and emotional needs.
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Findings included:
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1. Document review of the hospital's policy and procedure titled, "Seclusion/Restraint/Physical Hold," policy # 1000.53 reviewed 05/18, showed that updates to the Treatment Plan of Care must be completed within 24 hours to reflect seclusion/restraint intervention and changes in treatment approach if indicated.
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2. On 05/15/19, Investigator #9 conducted a closed record review of five (5) patients placed in seclusion or restraints. In 2 of 5 records reviewed, (Patients #901 and #902) staff failed to update the patients' care plans to reflect seclusion/restraint interventions.

3. At the time of the record review, Investigator #9 interviewed the Nurse Manager (Staff #901) about the missing treatment plans. The staff member confirmed the finding.

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