The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

EVERGREENHEALTH MEDICAL CENTER 12040 NE 128TH STREET KIRKLAND, WA 98034 Jan. 12, 2012
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
Based on interview and review of hospital documents, it was determined that the hospital failed to assure that all drugs and biological were administered in accordance with approved medical staff policies and procedures. The hospital ' s failure to do so potentially placed patients at risk for drugs and biologicals prescribed by persons unauthorized to do so.

On 1/12/2011, the Manager of Patient Safety and Regulatory Compliance was asked to provide documentation that the medical staff had defined who had been approved to issue orders. The Manager confirmed that the language was not found in the medical staff policies and procedures, the medical staff bylaws or in the rules and regulations.

Portions of the rules and regulations were reviewed with the Manager, and were found to contain the following:
" 2. Orders and General Conduct of Care
2.1 Responsibility for patient care:
Practitioners privileged to write orders shall be responsible for the medical care and treatment of each of their patients in the Hospital, for the prompt completeness, accuracy and legibility of such patient ' s medical records and for the necessary special instructions to or regarding such patient ... "

The rules and regulations did not define which practitioners were privileged, nor was documentation provided from any other source to define who was privileged to issue orders.


In addition, the Director of Pharmacy was interviewed on 1/12/2011, and s/he was also unable to provide documentation that the medical staff had defined who could issue orders.

Reference CoP 482.22 Medical Staff