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. 28, 2015
VIOLATION: RESPIRATORY CARE SERVICES POLICIES Tag No: A1160
Based on interview and document review, the facility failed to have the policies and procedures guiding respiratory therapy services reviewed and approved by the Medical Director of Respiratory Services. Failure to assure services are delivered in accordance with medical staff directives places patient's at risk for unsafe care.

Findings include:

Of the respiratory specific policies and procedures reviewed by this investigator, including the newly revised Heliox policy, eight were not approved by the Medical Director of Respiratory Services.
? Policies and procedures:
o Helium Oxygen Therapy (pre and post incident)
o Plan for Provision of Care - Respiratory Therapy
o Lung Protective Ventilation Orders
o Measurement of Lung Volumes
o Adult Continuous Mechanical Ventilation
o Adult Ventilator Weaning Guidelines - APPROVED BY MEDICAL STAFF
o Medical Equipment Management Plan
o Spirometry - APPROVED BY MEDICAL STAFF
o Arterial Puncture for Blood Gas Analysis
o Arterial Blood Gas (ABG) Critical Values - APPROVED BY MEDICAL STAFF
o Proper Handling of Soiled Respiratory Equipment
o Adult Ventilator Weaning Guidelines - APPROVED BY MEDICAL STAFF