HospitalInspections.org

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Item #1 - Integrated Schedules

Based on observation, interview, and document review, the Governing Body failed to ensure that Swedish Cherry Hill Hospital maintained an individual staffing schedule specific to Cherry Hill Hospital staff and services and failed to ensure that the staff were not moved back and forth between separately licensed and certified hospitals on an as needed basis as if they were one hospital.

Failure to maintain a schedule specific to the hospital's departments, staff, and services limits the Governing Body's ability ensure that the separately certified hospital demonstrates compliance with the Conditions of Participation and risks quality patient care and outcomes.

Findings included:

1. Document review of a hospital policy titled, "Dialysis Services Department Structure-Cherry Hill, First Hill, and Issaquah," approved 05/20, showed the following:

a. Core staffing is utilized. The core staffing is based on an average number of runs per day at each campus.

b. When dialysis staffing needs are identified each day, staff are assigned as to which campus to provide services.

c. If the dialysis needs are greater than staff allows, other non-scheduled dialysis staff will be contacted to see if they would work an additional shift or the Acute Care Services of the NW Kidney Center can be called to provide dialysis at Cherry Hill campus.

d. Staff on First Hill campus are on call after hours. If needs arise, they are contacted via pager by the charge nurse of the Nephrology Unit.

2. On 10/04/23 at 9:12 AM, Investigator #5 interviewed the Manager of the Interventional Radiology (IR) Lab (Staff #509) related to IR Staffing at Swedish Cherry Hill Hospital and reviewed a 6-week schedule for the IR Lab. Staff #509 stated that the Interventional Radiology Department is the "Department" and staff work at both campuses (Swedish Cherry Hill Hospital and Swedish First Hill Hospital). Staff #509 stated that all staff are initially scheduled on one schedule. It is not specified on the schedule where they will work. Then, each day they look at the staffing needs at Swedish Cherry Hill Hospital and Swedish First Hill Hospital and determine where staff need to work.

3. Investigator #5 reviewed the staff schedule provided for the time period of 09/24/23 through 10/21/23 and verified that the schedule reflected one, integrated staffing schedule that showed that all staff were generically scheduled a shift that did not reflect a location. Investigator #5 and Staff #509 reviewed the schedule specific for this day, and Staff #509 stated to Investigator #5 which hospital each staff was sent to work for the day. On this day, 4 RN'S from the department worked at Swedish Cherry Hill Hospital and 1 RN worked at Swedish First Hill Hospital. Also, 9 Cardio-Vascular Technicians worked at Swedish Cherry Hill Hospital and 3 Cardio-Vascular Technicians worked at Swedish First Hill Hospital.

Staff #509 stated that staff sign up for on-call shifts and that there is a call team assigned for each "campus" each night.

4. At this time, Investigator #5 and Staff #509 also reviewed the Vascular Access Team (VAT) schedules. Staff #509 stated that the VAT is a "Department" and staff for 4 Campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital, Swedish Ballard Hospital, and Swedish Issaquah Hospital). Staff #509 stated that the VAT staff have set schedules at each campus and open slots are filled with per diem staff. Staff #509 stated that historically, staff were hired and assigned to a facility, but that new staff are now hired to the "Department" and will float to Swedish Cherry Hill Hospital and Swedish First Hill Hospital. Staff #509 stated that as the manager, he is responsible for the department schedule and signing off on all incentive shifts.
Investigator #5 reviewed the VAT Department schedule for the time-period of 09/24/23 through 11/04/23. The review showed one schedule with staff assigned to all 4 hospitals.

5. On 10/04/23 at 10:15 AM, Investigator #5 interviewed the Centralized Monitoring Services Manager (CMU) (Staff #516). Staff #516 stated that the CMU is shared service department that provides remote cardiac telemetry monitoring and remote patient observation monitoring for 5 campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital, Swedish Ballard Hospital, Swedish Edmonds Hospital, and Swedish Issaquah Hospital). Staff #516 stated that the CMU Department staff are physically located at the First Hill Campus (Swedish First Hill Hospital) and the department is staffed with Telemetry Technicians and Nurses.

6. On 10/04/23 at 10:39 AM, Investigator #5 interviewed the Nurse Manager for Dialysis (Staff #517) and the Accreditation Manager (Staff #518). Staff #517 stated that the Dialysis Department is a "Multi-Campus" department who provides dialysis services to 3 Swedish Campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital and Swedish Issaquah Hospital).

Staff #517 stated that there is one schedule for the department and each day the charge nurse looks at which campus patients need dialysis, and that staff are told which campus they need to go to.

7. Investigator #5 reviewed the staff schedule provided for the time period of 09/24/23 through 11/04/23 and verified that the schedule reflected one, integrated staffing schedule that showed that all staff were generically scheduled a shift that did not reflect a location. Investigator #5 and Staff #517 reviewed the schedule specific for this day, and Staff #518 stated to Investigator #5 which hospital each staff was sent to work for the day. On this day, the Charge Nurse was at Swedish First Hill Hospital, 2 Registered Nurses (RN's) from the department worked at Swedish Cherry Hill Hospital, 6 RN's from the department worked at Swedish First Hill Hospital, and 2 RN's from the department worked at Swedish Issaquah Hospital. Staff #518 also stated there are also 2 Dialysis Technicians in the department that work between the campuses to manage the dialysis machines. Each campus has their own dialysis machines.

8. The Accreditation Manager (Staff #518) stated that the Dialysis Structure is a shared service similar to Physical Environment and the power in that is that they don't have one campus failing, they can share resources so there is no crisis, there is a structure to fall back on.

9. On 10/05/23 at 9:15 AM, during interview with Investigator #5, a Board of Trustee Member (Staff #525) stated that the Governing Body is a Swedish System Services Governing Body and that they report to the Swedish Health Systems Board of Trustees. They are responsible for looking at policy, new initiatives, oversite, and major concerns that require high level oversite. She stated she and the Board is aware of any issues that come up to that level.

Item #2 - Shared Services

Based on observation, interview, and document review, the hospital failed to ensure independent compliance with federal regulations and Medicare Conditions of Participation for Hospitals by sharing hospital services and staff with another separately certified health care entity.

Failure to provide effective oversight of services and staff can lead to dependence on another health care entity for compliance with federal regulations and put patients at risk of inconsistent care.

Findings included:

1. The hospital failed to ensure that Swedish Cherry Hill Hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the quality of the patient care provided by nursing services.

Cross Reference: A0386

2. The hospital failed to have an effective system in place to evaluate the quality of care provided by contracted services (formal contracts, joint ventures, informal agreements, shared services, or lease arrangements) for 3 of 3 shared services reviewed.

Cross Reference: A084

Due to the scope and severity of deficiencies cited under 42 CFR 482.12, the Condition of Participation for Governing Body was NOT MET.
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Based on interview, document review, review of the hospital's quality and performance improvement program, and review of Governing Body documents, the Governing Body failed to ensure that the hospital had an effective system in place to evaluate the quality of care provided by contracted services (formal contracts, joint ventures, informal agreements, shared services, or lease arrangements) for 3 of 3 shared services reviewed.

Failure to ensure that patient care services, and all other services, provided under contract are subject to the same hospital-wide quality assessment and performance improvement (QAPI) evaluation as other services provided directly by the hospital risks ineffective and unsafe healthcare to patients.

Reference: §482.12(e) Standard: Contracted Services The governing body must be responsible for services furnished in the hospital whether or not they are furnished under contracts. The governing body must ensure that a contractor of services (including one for shared services and joint ventures) furnishes services that permit the hospital to comply with all applicable conditions of participation and standards for the contracted services.

Findings included:

1. Document review of the Swedish Medical Center Policy titled, "Service and Product Supply Contracts: Selection and Evaluation," approved 10/22, showed the following:

a. Population Covered: All contracted services and products provided to Swedish Health Services.

b. Campuses: Ballard, Cherry Hill, First Hill, Issaquah, Mill Creek, Redmond.

c. The purpose of the policy is to ensure the same level of high-quality, safe, effective care and other services is delivered to patients regardless of whether services are provided directly by Swedish staff, or through contractual arrangements.

d. Certain services may be provided to patient or facilities through contractual arrangements. The Board of Trustees has delegated responsibility for the selection, contracting, monitoring, and ongoing evaluation of contracted services to Management.

e. A service Contract is defined as a formal written agreement for care treatment, and/or services provided to Swedish Health Services by an independent organization, group, agency, or individual ...

2. On 09/06/23 at 4:30 PM, during interview with Investigator #5, the Swedish Regional Chief Nurse Executive for the Central Service Area (CNO) (Staff #522), Staff #522 stated that the Telemetry and Dialysis Departments are multicampus departments and the matrices are embedded into the Swedish Quality Program. EQVR's (incident/variance reporting program) are used to determine if there are problems. The EQVR's are tracked and trended through the Quality Diffusion System, and the program will decide if it is a system problem or if it needs to go back to the specific campus. Staff #522 stated that there is no shared service quality score card and that they do not pull out any matrix separate for Cherry Hill Hospital.

3. At this same time, during interview with Investigator #5, the Senior Director of Accreditation (Staff #519) verified that Swedish Cherry Hill Hospital specifically did not provide oversight or collect quality data for the Remote Telemetry and Patient Observation Department. She stated there was not a need for a contract or memorandum of understanding (MOU) as the Remote Telemetry Department was a shared service provided by system employees, and that they were all system employees, and oversight was provided as part of the Swedish System Structure.

4. On 10/04/23, Investigator #5 reviewed Swedish Cherry Hill Hospital Quality Committee minutes provided to the Investigator, dated 10/13/22, 12/08/22, 01/12/23, 02/09/23, 03/09/23, 04/13/23, 05/11/23, 06/08/23, 07/13/23, 09/14/23. Investigator #5 found no evidence quality data reported or process improvement activities for shared services provided at Swedish Cherry Hill Hospital including, Dialysis Services, Remote Telemetry and Patient Observation Monitoring and the System Staffing Float Pool.

5. On 10/05/23 at 9:30 AM, during review of the Quality Program, Investigator #5 asked the Governing Body representative, Board of Trustee Member (Staff #525) what processes the Governing Body had in place to ensure that the hospital's Quality Program included all departments and clinical services provided to Cherry Hill Hospital. Staff #525 stated that the Governing Body is a Swedish System Services Governing Body and that they report to the Swedish Health Systems Board of Trustees. They are responsible for looking at policy, new initiatives, oversight, and major concerns that require high level oversight. She stated that the Board is aware of any issues that come up to that level.


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Based on interview and document review the hospital failed to ensure that it included quality measures for services provided to hospital patients by a "shared service" provided by Swedish Health Services System as part of their hospital wide quality program and used data collected to monitor the effectiveness and safety of the services and quality of care.

Failure to measure, analyze, and monitor the effectiveness and safety of services and quality of care of all hospital department and services (including those services furnished under contract or arrangement) limits the hospital's ability to ensure that process improvement is developed and implemented, and improvements are sustained to ensure improved healthcare outcomes.

Findings included:

1. Document review of the Swedish Quality Management System Quality Overview 2021," approved 04/20/21, showed the following:

a. Each campus defines quality improvement goals, which are derived from the five-year strategic plan. Acute Care goals, the Quadruple Aim, and the Institute and Services Program plans, as applicable.

b. Additionally, Swedish regional goals and campus-specific priority-driven improvement goals are created based on the unique needs of each campus, patient population, and community it serves, including adverse events and the risk-rating of quality improvement opportunities.

c. Campus-based committees, starting with the Campus Quality Council, are in place to operationalize system and local initiatives.

Document review of a hospital policy titled, "Dialysis Services Department Structure-Cherry Hill, First Hill, and Issaquah," approved 05/20, showed the following:

a. The purpose of the plan is to provide a reference source of information in the daily management and operations of the Dialysis Department on Cherry Hill, First Hill, and Issaquah campuses of Swedish Medical Center.

b. The purpose of the Dialysis Department performance improvement plan is to improve and assure delivery of quality patient care. To ensure quality patient care, the dialysis department staff continually measure, assess, and improve processes and systems that relate to patient care, including performance standards that affect patient care outcomes.

c. The Nurse Manager of the Nephrology Unit has the overall responsibility for leadership in the development, implementation, and monitoring of the performance improvement activities.

d. Performance improvement program objectives include establishment of a unit-based performance improvement plan that reflects the organizational and nursing department plans and meet the dialysis department unit requirements.

e. Dialysis department staff meetings are the forum in which information regarding performance improvement and quality control monitoring are presented and discussed. Solicitation of identified or perceived problems, participation in process development, and establishment of a sub committee of staff to work on selected problems also occurs in the staff meeting format.

f. The Committee structure for the Dialysis Department involves representation and/or membership on selected hospital, nursing, and medical staff committees including Shared Leadership and various ad hoc and quality committees.

Document review of the Quality Reporting Calendar for 2022 titled, "Swedish Cherry Hill Quality Council 2022 Reporting Calendar," showed that Infection Prevention reported to Quality on 10/13/22.

Document review of the Quality Reporting Calendar for 2023 titled, "QM.7-Measurement, Monitoring, Analysis-2023," showed that Infection Prevention reports to Quality in January, May, and November.

2. On 09/06/23 at 4:30 PM, Investigator #5 interviewed the Swedish Regional Chief Nurse Executive for the Central Service Area (CNO) (Staff #522). Staff #522 stated that the Telemetry and Dialysis Departments are multicampus departments and the matrices are embedded into the Swedish Quality Program. EQVR's (incident/variance reporting program) are used to determine if there are problems. The EQVR's are tracked and trended through the Quality Diffusion System, and the program will decide if it is a system problem or if it needs to go back to the specific campus. Staff #522 stated that there is no shared service quality score card and that they do not pull out any matrix separate for Cherry Hill Hospital.

3. At this same time, during interview with Investigator #5, the Senior Director of Accreditation (Staff #519) verified that Swedish Cherry Hill Hospital specifically did not provide oversight or collect quality data for the Remote Telemetry and Patient Observation Department. She stated there was not a need for a contract or memorandum of understanding (MOU) as the Remote Telemetry Department was a shared service provided by system employees, and that they were all system employees, and oversight was provided as part of the Swedish System Structure.

4. On 09/06/23 at 4:45 PM, Investigator #5 reviewed a note from an Accreditation Manager (Staff #518) in regards to a request for a contract/agreement and information on how quality of services is measured for the Remote Cardiac Telemetry and Patient Observation Unit services provided to Swedish Cherry Hill patients by a shared service. The note stated, "We do not have a contract or memorandum of understanding for cardiac monitoring provided by the EICU. This is a shared service. Therefore, no specific quality metrics tracked to monitor contract performance as there is no contract."

5. On 10/04/23 at 10:15 AM, Investigator #5 interviewed the Centralized Monitoring Services Manager (CMU) (Staff #516). Staff #516 stated that the CMU is shared service department that provides remote cardiac telemetry monitoring and remote patient observation monitoring for 5 campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital, Swedish Ballard Hospital, Swedish Edmonds Hospital, and Swedish Issaquah Hospital). Staff #516 stated that he did not collect quality data, he did "spot checks" but did not document or submit quality data. Staff #516 stated that any concerns are documented in an EQVR and are reported to the Critical Care Council, which is a group of nurse leaders and physician leaders who meet once a month to discuss critical care services throughout the organization.

6. On 10/04/23 at 10:39 AM, Investigator #5 interviewed the Nurse Manager for Dialysis (Staff #517) and the Accreditation Manager (Staff #518). Staff #517 stated that the Dialysis Department is a "Multi-Campus" department that provides dialysis services to 3 Swedish Campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital and Swedish Issaquah Hospital).

7. At this time, Investigator #5 asked how quality information including water cultures was tracked and reported at Cherry Hill Hospital. Staff #518 stated that information is stratified by campus. For example, the "Culture Book" is located at Swedish First Hill Hospital, but results are reported out at the Cherry Hill Campus (Swedish Cherry Hill Hospital).

8. On 10/04/23, Investigator #5 reviewed a Power Point Document titled, "Dialysis Cultures Qtr. 3, 2022," that stated, "1 machine over action level for colony count," and "machines are held out of routine service until a negative culture is received. If machine or RO above action level, it is disinfected again and recultured and held out of service until negative culture obtained."

The Document did not identify the hospital where the positive culture was identified (Swedish Cherry Hill Hospital, Swedish First Hill Hospital or Swedish Issaquah Hospital).

9. Handwriting on the document stated that the document was presented to the Swedish System Infection Prevention Committee.

10. On 10/04/23, Investigator #5 reviewed committee minutes titled, "Infection Prevention System Meeting," dated 11/23/22. The document showed, "1 machine over action level for colony count." The document did not identify the hospital where the positive culture was identified (Swedish Cherry Hill Hospital, Swedish First Hill Hospital or Swedish Issaquah Hospital).

11. Investigator #5 reviewed Swedish Cherry Hill Hospital Quality Committee minutes provided to the Investigator, dated 10/13/22, 12/08/22, 01/12/23, 02/09/23, 03/09/23, 04/13/23, 05/11/23, 06/08/23, 07/13/23, 09/14/23. Investigator #5 found no evidence of dialysis quality data reported specific to Swedish Cherry Hill Hospital.

12. On 10/05/23 at 9:30 AM, during the Quality Program Review, Investigator #3, asked the Quality Committee which hospital had the dialysis machine with the positive cultures. Committee members did not know. Staff #519 stated she would find that information.

13. On 10/05/23 at 10:15 AM, Investigator #5 and Investigator #3 reviewed an email chain from time-period 10/05/23 at 9:34 AM to 10/05/23 at 9:45 AM, which showed that the Dialysis Manager (Staff #517) was able to look back at the data and stated that the machine with the positive growth reported in minutes to the System Infection Control Committee on 11/23/22 occurred at Swedish Cherry Hill Hospital. The email also stated that if a culture comes back positive it is disinfected and re-cultured and not used until the culture is negative.

14. A yellow sticky note adhered to the documented titled, "Dialysis Cultures QTR 3-2022," stated, "System Infection Prevention reports cultures end of Quarter 3, if issues identified it will be part of the IP's report out at Cherry Hill Quality Council November 2023."
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Based on interview and document review, the hospital failed to ensure that Swedish Cherry Hill Hospital operated with one hospital-wide Nursing Service, and failed to ensure that a single nursing service was under the direction of one Registered Nurse (RN) responsible for the quality of the patient care provided by nursing services.

Failure to ensure that Nursing Services are provided under the direction of a hospital-wide nursing service under the direction of one Registered Nurse places patients at risk for suboptimal care, adverse outcomes, and death.

Findings included:

1. Document review of the hospital's document titled, "Swedish Cherry Hill-Functional Org Chart," dated 08/01/23, did not include a line of reporting for the Swedish Health System Dialysis Program or the Swedish Health System Remote Telemetry and Patient Observation Unit.

Both departments provide nursing services to patients admitted to Swedish Cherry Hill Hospital.

Remote Cardiac Telemetry Monitoring and Patient Observation Monitoring

2. On 09/06/23 at 1:15 PM, Investigator #5, the Cardiac Telemetry Relief Charge Nurse (Staff #505), and a Cardiac Clinical Nurse Specialist (Staff #502) inspected the Telemetry Department on 2 East. During the inspection Investigator #5 asked how cardiac telemetry monitoring was provided for patients at Swedish Cherry Hill Hospital. Staff #502 and #505 stated that Telemetry Monitoring Services were provided remotely by Swedish First Hill Hospital.
Investigator #5 requested Swedish Cherry Hill Hospital's contract or agreement for the Telemetry Services.

3. On 09/06/23 at 4:30 PM, during interview with Investigator #5, the Senior Director of Accreditation (Staff #519) verified that Swedish Cherry Hill Hospital specifically did not provide oversight or collect quality data for the Remote Telemetry and Patient Observation Department. She stated there was not a need for a contract or memorandum of understanding (MOU) as the Remote Telemetry Department was a shared service provided by system employees, and that they were all system employees, and oversight was provided as part of the Swedish System Structure.

4. On 10/04/23 at 10:15 AM, Investigator #5 interviewed the Centralized Monitoring Services Manager (CMU) (Staff #516). Staff #516 stated that the CMU is shared service department that provides remote cardiac telemetry monitoring and remote patient observation monitoring for 5 campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital, Swedish Ballard Hospital, Swedish Edmonds Hospital, and Swedish Issaquah Hospital). Staff #516 stated that the CMU Department staff are physically located at the First Hill Campus (Swedish First Hill Hospital) and the department is staffed with Telemetry Techs and Nurses.

Staff #516 stated that he reported to the Director of Critical Care and Emergency Services at Swedish First Hill Hospital and this person reported to the Chief Nursing Officer at Swedish First Hill Hospital.
Dialysis Program

5. On 09/06/23 at 3:50 PM, Investigator #5 observed a Dialysis Nurse (Staff #520) set up and provide dialysis to Patient #505. At the time of the interview, Staff #520 stated that he reported to the Nurse Manager of the Dialysis Department and 11 East Department at Swedish First Hill Hospital (Staff #521). He stated that his supervisor (Staff #521) reported to the Swedish First Hill Hospital Chief Nursing Officer (CNO) (Staff #523).

6. On 09/06/23 at 4:30 PM, during interview with Investigator #5, the Senior Director of Accreditation (Staff #519) stated that Dialysis Services was a Multi-Campus Department under the oversight of Staff #521 who was a Multi-Campus Manager who reported to the Swedish Regional Chief Nurse Executive for the Central Service Area (Staff #522). She stated that there was not a contract or agreement with Dialysis Services as there was not a need as it was a shared service provided by system employees, and that they were all system employees.

7. On 09/08/23 at 12:00 PM, during interview with Investigator #5, the Swedish Regional Chief Nurse Executive for the Central Service Area (CNO) (Staff #522) stated that Swedish Health Systems in a singular employer who operates under one UBI Number (Unified Business Identifier) and a Collective Bargaining Agreement (CBA). She stated that Swedish Health Systems operated separate from Providence Health Systems and that under the CBA Swedish Health Systems bargained related to floating staff from campus to campus. Staff #522 stated that the Dialysis Department and all Shared Service Departments report to their respective managers, who then report to the CNO at each respective campus, who then report up to her (the System CNO).

8. On 10/04/23 at 10:39 AM, Investigator #5 interviewed the Nurse Manager for Dialysis (Staff #517) and the Accreditation Manager (Staff #518). Staff #517 stated that the Dialysis Department is a "Multi-Campus" department who provides dialysis services to 3 Swedish Campuses (Swedish Cherry Hill Hospital, Swedish First Hill Hospital and Swedish Issaquah Hospital).

Staff #517 stated that he reported to the Director of Acute Care at Swedish First Hill Hospital and that that person reported to the Chief Nursing Officer at Swedish First Hill Hospital.

9. On 10/05/23 at 8:49 AM, during interview with Investigator #5, the Chief Nursing Officer for Swedish Cherry Hill Hospital (Staff #524) stated that the Shared Service Departments, including Dialysis, the System Nursing Float Pool, and the Remote Telemetry and Observational Monitoring Unit, were not in her line of reporting but that Swedish Health Services is a Matrix organization and information is shared in the Tiered Huddles.

10. At this time, a Quality Program Manager (#528) stated that system employees including nurses may not have a direct line to the CNO (Swedish Cherry Hill CNO), but Quality is looked at as a system. A Quality Program Manager (Staff #526) and a System Director of Quality (Staff #527) agreed that this was the process for Swedish Health Systems.

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Item #1 - Clinical Evaluations

Based on interview and document review, the hospital failed to ensure the Chief Nursing Officer or designated qualified hospital registered nurse conducted clinical evaluation activities of supplemental non-hospital nursing personnel who provided patient care.

Failure to evaluate the nursing care provided by non-hospital personnel by a qualified hospital registered nurse risks patients receiving inconsistent or inadequate care.

Findings included:

1. Document review of the hospital policy titled, "Staffing Inpatient Nursing Units - Daily Process," PolicyStat ID # 10140921, last approved 02/21 showed that the Swedish Transfer and Operations Center (STOC), the Nursing Supervisor, and the Clinical Resource Office (CRO) (staffing office) specialist will collaborate twice daily to discuss staffing assignments and system wide needs and make staffing decisions that best meets patient care needs. The nursing float pool staff are assigned by the CRO to nursing units where they can be utilized best based upon skill level and patient need.

Document review of the hospital policy titled, "Swedish Transfer and Operations Center (STOC) Department Structure - Ballard, Cherry Hill, Edmonds, First Hill, Issaquah, Mill Creek, and Redmond," PolicyStat ID # 1163982, last approved 11/20 showed that all caregivers are evaluated annually by the manager. Evaluation is a process of self-evaluation, peer evaluation, and manager evaluation.

2. Review of the hospital document titled, "Functional Org Chart for STOC" (organizational reporting structure) showed that the Nursing Manager for the Multi-Campus float pool (Staff #301) reports directly to the Executive Director of Clinical Operations at Providence Swedish (Staff #302). Staff #302 reports to the Senior Vice President Chief Nursing Office for Providence Healthcare System (Staff #303).

3. On 09/08/23, Investigator #5 reviewed the Human Resource File for 1 multi-campus shared service dialysis staff (Staff #520). The review showed that staff did not report to nurse managers at Swedish Cherry Hill Hospital and did not have an annual performance appraisal by a member of the Swedish Cherry Hill Hospital nursing leadership.

4. On 09/08/23 at 12:00 PM, during interview with Investigator #5, the Swedish Regional Chief Nurse Executive for the Central Service Area (Staff #522) stated that Dialysis and Remote Telemetry are shared services who report to a hospital manager who report up to a hospital Chief Nursing Executive who then report to her. Competencies and reviews flow up to her as the Regional Chief Nurse and all the Swedish campuses follow the same metrics. Staff #522 verified that the Manager and the CNO that a multicampus shared service reports up through may not be a Swedish Cherry Hill Nurse Manager or Swedish Cherry Hill Chief Nurse Executive.

5. On 10/04/23 at 12:00 PM, Investigator #3 and #17 interviewed the Swedish Healthcare System Nursing Manager for the Swedish Multi-Campus float pool (Staff #301). Staff #301 stated that he supervises a multi-campus nursing float pool which provides registered nurses to 4 Swedish hospitals and freestanding emergency departments in the central service area. He specifically manages registered nurses which go to medical-surgical telemetry units, intensive care units, and emergency departments throughout the central service area. Service line directors oversee and direct multi-campus float pools for other specialties such as obstetrics and perioperative services.

Next, Investigator #3 asked Staff #301 about how multi-campus nurses who work for the Swedish Healthcare System are evaluated. He stated his assistant and him write the performance evaluation for the multi-campus staff by doing quarterly "check-ins" with the managers in the system. Staff #301 acknowledged it is more of a "pull process" to get feedback. Staff #301 also stated that the float pool management staff perform periodic rounding in the hospitals to observe those nurses.

6. On 10/05/23 between the hours of 8:33 AM to 10:30 AM Investigator #1 and Investigator #17 reviewed 11 employee staff files with Human Resources Manager (Staff #106). The review showed that 5 of 5 multi-campus float pool staff (Staff #101, Staff #102, Staff #103, Staff #104, and Staff #105) and 2 of 2 float pool dialysis nurses (Staff #109 and Staff #110) did not have an annual performance appraisal by a member of the Swedish Cherry Hill Hospital nursing leadership.

7. On 10/05/23 at 10:10 AM, Investigator #1 interviewed the Human Resources Manager (Staff #106). Staff #106 stated that the multi-campus float pool evaluations were completed by the Swedish Healthcare System nursing manager and his assistant (Staff #107 and Staff #108) who oversee the multi-campus float pool staff.

During the review, Investigator #1 received documentation of evaluations for Staff #109 and Staff #110 by the Swedish First Hill Dialysis Nurse Manager (Staff #111). Documentation showed evaluations were completed by Swedish First Hill Dialysis Nurse Manager (Staff #111). Staff #111 confirmed that she completed both evaluations.

Item #2 - Unit Orientation

Based on interview and review of personnel files, the hospital failed to ensure dialysis float pool nurses were oriented to their job responsibilities at the Swedish Cherry Hill Campus for 2 of 2 dialysis float pool registered nurse file reviewed (Staff #109, and Staff #110).

Failure to ensure staff members are oriented to their work environment and job responsibilities risks inappropriate patient placement and poor patient outcomes.

Findings included:

1. On 10/04/23 at 10:51 AM, Investigator #1 interviewed a dialysis float pool registered nurse (Staff #109) regarding unit orientation. Staff #109 indicated that she was hired at Swedish First Hill Hospital as a float dialysis nurse and her unit orientation for Swedish Cherry Hill Hospital consisted of a walk through of the environment. Staff #109 indicated that unit orientation was not documented.

2. On 10/04/23 at 11:30 AM, Investigator #1 interviewed a dialysis registered nurse (Staff #110) regarding unit orientation. Staff #110 indicated that he was hired at Swedish First Hill Hospital as a float dialysis nurse and that when he went to other facilities, he was given an overview of job responsibilities.

3. On 10/05/23 between the hours of 8:33 AM to 10:30 AM Investigator #1 and Investigator #17 reviewed 11 employee staff files with Human Resources Manager (Staff #106). The review showed that 2 of 2 Dialysis Registered Nurses (Staff #109, and Staff #110,) did not have documentation for unit orientation specifically for Swedish Cherry Hill Hospital.

4. On 10/05/23 between the hours of 8:33 AM to 10:30 AM, during an interview with the Human Resources Manager (Staff #106) indicated that staff #109 and staff #110 were hired at Swedish First Hill Hospital and was unable to find unit orientation specifically for Swedish Cherry Hill for staff #109 and #110.
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