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.

WESTERN STATE HOSPITAL 9601 STEILACOOM BLVD SW TACOMA, WA May 2, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
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Based on observation, interview, and document review, the hospital's Governing Body failed to meet the requirements at 42 CFR 482.12 Condition of Participation for Governing Body due to the following failures:

Findings:

The Governing Body failed to effectively manage the functioning of the hospital to protect patients and staff from harm as evidenced by the (2) two immediate jeopardy conditions identified on 4/29/2016 in the following areas:

1. Failure to adequately monitor and intervene for assaultive behavior.

2. Failure to train, supervise and provide sufficient numbers of competent patient care staff who care for patients requiring 1:1 monitoring.

3. Failure to develop and implement effective patient monitoring procedures for assaultive behavior.

4. Failure to implement an effective risk reduction strategy for items identified as high risk on annual Environment of Care physical risk assessments.

5. Failure to conduct effective daily and monthly environmental safety rounds for identification of hazards associated with elopement, ligature, and patient safety.

Due to the scope and severity of deficiencies detailed under 42 CFR 482.13 Condition of Participation for Patient Rights and 42 CFR 4282. 41 Condition of Participation for Physical Environment, the Condition of Participation for Governing Body was NOT MET.

Cross Reference: Tags A0115; A0700
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VIOLATION: PATIENT RIGHTS Tag No: A0115
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Based on staff and patient interviews, observations, review of hospital policies and procedures, and document review, the hospital failed to ensure that patient rights were protected and promoted by:

1. Failure to investigate and resolve patient and family complaints prior to closure of the complaint;

2. Failure to follow hospital procedure in response to patient allegations of staff sexual abuse;

3. Failure to supervise staff assigned to 1:1 monitoring of a patient who was assessed as a danger to others that resulted in a patient to patient sexual assault;

4. Failure to follow hospital procedure to obtain a physician's order prior to using a restraint device to transfer a patient to another room; and

5. Failure to ensure that patients had independent access to clean drinking water.

The cumulative effects of these systemic problems resulted in the hospital's inability to protect patient rights.

Due to the scope and severity of deficiencies cited under 42 CFR 482.13, the Condition of Participation for Patient Rights was NOT MET.

Cross References: Tags A0123, A0145, A0159, and A0397.
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VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
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Based on observation, interview, record review, and review of hospital policy and procedure, the hospital failed to ensure that patient grievances were investigated, and the patients who filed them were notified of the results of the grievance process to resolve patient complaints in a timely manner for 4 of 7 patient grievances reviewed (Patient's #1, #4, #5, and #6).

Failure to promptly address patient grievances risks patient safety and delayed treatment for unmet care needs.

Findings:

1. The hospital policy and procedure titled "Grievance/Complaint Resolution and Response" (Revised 12/31/2015) read in part:

"WSH (Western State Hospital) will provide timely response to patient complaints, including allegations of patient rights violations, ensuring the patient receives fair and courteous treatment. If the grievance cannot resolve within 7 days, a letter of acknowledgement must be sent and will include the anticipated date when the grievance resolution/response will be completed;" and, "The designated staff/supervisor will meet with the patient to discuss the grievance and to work toward resolution. During this meeting, the patient is asked if the grievance has been resolved or if there are additional concerns. This response is noted on the Patient Grievance Resolution form."

2. Seven patient complaints were selected for review of process and resolution. Sources included the patient complaint log. Each was reviewed for evidence of receipt, hospital review, investigation, findings, and resolve of the grievance issue with the findings reviewed with the patient who filed the grievance.

3. Patient #1-Per record review, in June, 2014 the patient made multiple allegations of staff sexual abuse to various staff members, including to a social worker on June 3, 2014, a psychiatrist on June 5, 2014 and an occupational therapist assistant on June 16, 2014. None of the staff initiated a grievance or an incident report which would have triggered additional investigation and review. The patient filed a written grievance on June 16, 2014. There was no evidence that staff met with the patient to discuss findings of an investigation until August 13, 2014, 58 days after the written complaint was filed, and over 2 months from the first verbal report of sexual assault.

4. Patient #4 - Per review of the patient log documents, the patient complained on 2/3/2016 of being hit by another patient and wrote, "I don't feel safe here." On 2/4/2016, a letter/memo was sent from the Director of Patient Grievance Investigations (Staff Member #6) which read in part, "Your Grievance was forward(ed) to the Nursing Supervisor for further review." The electronic complaint system was reviewed for the findings and resolution of the complaint issue. The ticket entries assigned to this complaint, (Ticket ) were reviewed. Although the complaint was marked, "Complete" in the system, there was no evidence or documentation that this grievance, identified as a Patient Rights Violation, had been investigated, resolved, or discussed with Patient #4. There was no other documentation indicating that the issue had been received by the Nursing Supervisor, investigated, resolved, or discussed with Patient #4.


5. Patient #5 - Per review of the patient complaint log documents, Patient #5 filed a grievance dated 11/18/2015, regarding inability to qualify for a "level 3" privilege because of an inability to identify substances "by eye." The electronic complaint system was reviewed for the findings and resolution of the complaint issue. The ticket entries assigned to this complaint (Ticket ) were reviewed. Although the complaint was marked, "Complete" in the system, there was no evidence or documentation that this grievance, identified as a Patient Rights Violation, had been investigated, resolved, or discussed with Patient #5. There was no letter/memo from administrative staff that the grievance had been received or assigned to staff for investigation. There was no other documentation evidencing that the issue had been investigated, resolved, or discussed with Patient #5.


6. Patient #6 - Per review of the patient complaint log documents, the patient filed a grievance dated 1/24/2016, regarding a violent patient on the unit who was "threatening my life." On 1/26/2016, a letter/memo was sent from the Director of Patient Grievance Investigations (Staff Member #6) which read in part, "Your Grievance was forward(ed) to the Nursing Supervisors and your Doctor for further review." The electronic complaint system was reviewed for the findings and resolution of the complaint issue. The complaint was documented as referred to the "Lakewood Police Department", but there was no evidence or documentation that this grievance had been investigated, resolved, or discussed with Patient #6. There was no other system documentation indicating that the issue had been received by the Nursing Supervisors or Doctor as identified in the letter/memo of 1/26/2016, investigated, resolved, or discussed with Patient #6.

7. Interview with the Director of Patient Grievance Investigations (Staff Member #6) on 4/14/2016 at 9:10 a.m. revealed that there was no process by which the staff member identified in the hospital's letter/memo to the patient who was assigned to investigate the complaint (in these cases, the Nursing Supervisor, the Doctor, or in other instances the Treatment Team for the patient involved) was held accountable to complete the investigation, document and report the findings, and resolve the issue with the patient who filed the complaint.

The Patient Grievance Director position had no authority to follow up on the grievance process with staff to ensure the grievance was actually investigated, resolved, and closed as directed by the hospital's Grievance Procedure. There was no system in place to ensure the grievance procedure was completed.

The hospital failed to ensure that staff implemented the hospital's Grievance Resolution procedure to investigate patient complaints, and document the findings, resolution with the patient, and the date of completion.
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VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
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Based on observations, interviews and review of hospital documents, the hospital failed to implement effective procedures and staff training to protect patients from abuse or harassment from other patients, and failed to protect patients from staff neglect when water to a drinking fountain was shut off, and patients had to ask for access to drinking water.

Failure to train, supervise, and monitor staff to effectively implement hospital procedures risks patient health and safety.

Item #1 Patient Monitoring

Findings:

1. Patient #2 -Per hospital reports, the patient said she/he was sexually assaulted on 3/23/2016 when she/he slipped away from staff monitors and was found in a bathroom with a male patient (Patient #3).The patient to patient sexual assault occurred when an institutional counselor (Staff Member #7), who was assigned to monitor Patient #2 on a 1:1, "lost sight" of Patient #2 before discovering the two patients in a bathroom.

2. Review of Patient #2's behavior observation record for 3/23/2016 on the 1500 to 2200 shift, revealed it was filled out from 1500 to 1600 hours without a notation of the assault. The incident occurred at 1530 hours on 3/23/2016. The institutional counselor (Staff Member #7) assigned on a 1:1 monitor of Patient #2 falsely documented that the patient was in "Close" observation every 15 minutes, even when the incident occurred.

3. Review of additional behavioral monitoring sheets revealed inconsistency in the supervisory directives to the institutional counselor staff for the kind of monitoring required for patients based on assessment of the patient. For example:

a. Review of Patient #2's behavior observation record dated 3/22/2016 (the day prior to the incident) for the 0700 to 1400 shift showed no directives identified for the type of observation required.

b. On the day of the incident, 3/23/2016, the behavior observation record for the shift just prior to the incident, (the 0700 to 1400 shift) was marked for "Close" observation-but no summary of patient behavior was documented.

4. Similar findings of staff failure to protect patients and prevent on-going abuse or harassment from other patients were observed for Patient's #3, #8, #9 and #10:

a. Patient #3--(the patient involved in the sexual assault of Patient #2)--Per the hospital assault log, Patient #3 was involved with 10 patient to patient assaults from 10/19/2015 to 3/23/2016. Eight of the incidents were with Patient #10.

b. Patient #8--Per the hospital assault log, Patient #8 (assigned a 1:1 staff monitor) was involved in 9 assaults within a period of 3 weeks from 3/9/2016 to 3/30/2016, including four with injuries.

c. Patient #9--Per the hospital assault log, Patient #9 was involved in 7 patient to patient assaults from 9/6/2015 to 1/22/2016.

d. Patient #10--Per the hospital assault log, Patient #10 was involved with 10 patient to patient assaults from 10/19/2015 to 3/23/2016. Eight of the incidents were with Patient #3.

5. An interview with the Medical Program Director (Staff Member #5) of the Habilitative Mental Health Care Unit on 4/13/2016 at 11:55 AM identified that 1:1 monitoring assignment was to be in "close proximity/within arm's length" of the patient in order to redirect physical and sexual aggressive behaviors and agitation toward self or others.

6. Interviews with other patient care staff on 4/13/2016 at 11 AM identified 1:1 monitoring: "Close" monitoring: means within line of sight of the patient at all times and staff are to document on the behavioral observation record every 15 minutes; and "Constant" monitoring:- means within arm's length of the patient.

7. Interviews with administrative nursing staff (Staff Member #10) on 4/13/2016 and over the course of this investigation revealed the 1:1 policy and procedure was in draft form and under review.

Failure to train and supervise staff in the requirements and clear hospital directives to staff of 1:1 monitoring resulted in on-going patient to patient assaults.
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8. On 4/26/2016 at 9:00 AM, Investigator #3 and #4 interviewed the interim chief nursing officer (Staff Member #10) regarding the hospital policy for 1:1 monitoring. The investigators asked if there had been an update to the policy and if the hospital provided any staff education about the changes. Staff Member #10 indicated that the hospital had drafted a new policy titled "Enhanced Engagement" but the chief medical officer had not yet approved it. She/he stated that any new training would begin after the policy was formally adopted.
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9. On 4/27/2016 at 2:55 PM, Investigator #3 interviewed the research manager (Staff Member #8) about patient assaults and the hospital's use of 1:1 monitoring. Within the past year, the hospital had emphasized the use of one to 1:1 monitoring as an intervention to reduce restraint and seclusion usage. Staff Member #8 indicated at this time there was no data to show if the intervention of 1:1 monitoring was effective in reducing assaults. She/he stated the facility was in the process of modifying the AROI (incident report) process to include information on 1:1 monitoring in order to evaluate this variable against ongoing assault episodes. At this time, there was only anecdotal information that indicated staff felt 1:1 monitoring resulted in an increased number of assaults.
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10. On 4/29/2016 at 9:30 AM, Investigator #3 interviewed the quality manager (Staff Member #9) about patient assaults. She/he confirmed the hospital was collecting data on assaults and assaults with injuries but was not collecting data on those same categories for those patients ordered for 1:1 monitoring.

Item #2 - Access to drinking water

Findings:

1. An interview with a RN2 (Staff Member #19) on 4/13/2016 at 3:17 PM revealed that water to the water fountain on unit S7 had been ordered shut off by an RN3 and that the only free access to water that patients had was the bathroom sink or toilet.

The RN2 stated she/he was concerned that patients did not have access to drinking water and that patients had to ask for water if they wanted it. She/he felt that about 75% of patients would ask if they needed drinking water but that others would not. She/he had recently cared for a patient (Patient #11) that became dehydrated and this had increased her concern.

2. Review of Patient #11's medical record revealed the following:

The patient had an observed fall on 2/20/2016 at 1:40 AM. The medical doctor on-call was notified and orders were given. The orders included a blood draw for specific labs, urinalysis with culture and sensitivity, holding certain medications and vital signs and oximetry [oxygen saturation check] per falls protocol. The order also included "encourage po [oral] fluids" and "offer entire cup of fluid between meals x 2 days."

Per the RN2's (Staff Member #19) observation (as documented on 2/20/2016) Patient #11 presented with signs and symptoms of dehydration (dry skin with poor skin turgor, dry mouth and lips, excessive thirst, sunken eyes and upon waking extreme irritability). Patient #11's vital signs were assessed at 7:30 AM as follows: blood pressure (lying) 86/55, heart rate 94, respiratory rate 16, oxygen saturation 96% and temperature 98.7 (down from 101 degrees F. at 4:30 AM). The RN documented that the patient had elevated blood urea nitrogen (BUN), and C-reactive protein. Throughout the shift, nursing staff encouraged the patient to drink fluids (a total of 1560 mL consumed during day shift). On the evening shift, the patient's blood pressure was 133/86 (lying), heart rate was 91 and his/her temperature was normal. The RN2 documented that the patient drank another 1560 mL of fluid during the evening shift.

The RN2 concluded his/her note with " ...recommendation to "turn on" the water fountain on the ward as patients have no other means for obtaining water other than requesting water from staff or during meals."

When the RN2 was asked if she/he had notified anyone about his/her concerns she/he said no.

3. During a tour of unit S7 on 4/14/2016 at 9:34 AM, Investigator #3 had the following observations:

The water fountain was missing and the space was covered with a piece of plywood.

In the observation room located directly across from the nursing station, a cooler was visible through the window. An MHT3 (Staff Member #20) unlocked the door to the observation room and opened the lid of the cooler for the investigator to examine. The cooler was full of water. The water appeared to be clean. The MHT3 stated that the cooler was refilled with water as needed. She/he stated that when she/he cleans the cooler she/he fills it with hot water, adds a small amount of bleach and then dries the cooler with a towel after dumping out the bleach water. She/he stated that this was his/her process and she/he did not know how other staff cleaned the cooler. She/he also did not know how often the cooler was cleaned. There was no documentation indicating how often the cooler was cleaned. When asked how patients access the water cooler, the MHT3 stated that patients have to ask staff for water and that the observation room is locked.

The cleaning process or lack thereof is a violation of the FDA Food Code:

-Equipment-Manual and mechanical warewashing equipment, chemical sanitization-Temperature, pH, concentration, and hardness (2009 FDA Food Code 4-501.114)

-Drying-Equipment and utensils, air-drying required (2009 FDA Food Code 4-901.11).

In the laundry room, Investigator #3 observed a utility sink as another place where patients could get drinking water. The laundry room is locked so patients must ask staff to open the door so they can fill their water bottles with drinking water.

The MHT3 (Staff Member #20) stated that there was no drinking water available that patients could access without asking a staff member to unlock a door.

4. An interview with the RN3 (Staff Member #21) for unit S7 on 4/14/2016 at 9:50 AM revealed that a patient (Patient #9) was transferred to S7 from S10 in February. The RN3 stated the patient suffered from polydipsia (abnormally great thirst), the patient would run to the water fountain and drink excessive amounts of water - this behavior was habitual. She/he stated that the patient was also known to be a danger to others and had an assigned 1:1 monitor. Because of the difficulty in keeping the patient away from the water and fear that the patient would become assaultive if prevented from drinking the water, the RN3 called maintenance and requested that the water fountain be turned off.

When Investigator #3 asked if the water was shut off on S10 where Patient #9 was cared for prior to his/her transfer to S7, the RN3 said no.

According to maintenance documentation, the water to the water fountain on unit S7 was shut off on 2/12/2016 and had not been turned back on. As of the date of this investigation, the water had been turned off for 56 days, just short of 2 months.

5. The Plumbing Shop Supervisor (Staff Member #23), Facilities Coordination Manager (Staff Member #4), the Chief Operations Officer (Staff Member #22), and the Interim Chief Nursing Officer (Staff Member #10) requested to speak to Investigator #3 on 4/14/2016 at 12:30 PM. They presented the following information during the meeting:

On 2/16/2016 a work order was received requesting that water be turned off on ward S7.

The work order was completed on 2/16/2016.

There was no other documentation indicating that water had been turned back on at any time prior to 4/14/2016.

By the end of the day on 4/14/2016, the water fountain would be put back in place - until then, bottled water would be provided for patients on S7

. Patient #12 had pulled the water fountain away from the wall on 3/24/2016. A work order was submitted on the same day requesting that the water fountain be removed for safety. The work order was completed on 3/25/2016. Under the section titled "Results" on the work order it read "There are now no water fountains on the ward as per instructed by nursing ward charge."

According to the policy and procedure titled "Work Request: Repairs and Minor Alterations" (Policy #1.2.2; Revised 12/30/2015) work orders were to be approved by the Discipline Supervisor(s) [such as a psychiatrist], Office Supervisor, Center Directors or Nurse Managers [RN4].

The RN3 (Staff Member #21) that submitted the work order to shut off the water to the water fountain on 2/12/2016 was not authorized to approve the requested work.

6. By the time the investigators left the facility on 4/14/2016, the investigators were notified that the water fountain had been repaired and put back in place on unit S7.
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VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0159
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Based on record review, interview and review of hospital policy and procedure, the hospital failed to follow its policy and procedure for restraint use for 1 of 1 patients reviewed (Patient #7).

Failure to follow hospital policy and procedure for restraint use places patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings:

1. The hospital's policy titled "Management of the Patient in Seclusion and Restraint" (Protocol 302; Revised December 2015) defined a restraint as "Any manual method, physical or mechanical device, material or equipment that immobilizes or reduces the ability of the patient to move his or her arms, legs, body or head freely ... "

In addition, under the section titled "Care Directives" the policy read in part the "RN [Registered Nurse] obtains order from attending psychiatrist ..."

2. Review of the hospital's policy titled "Med Sled Pull for Safe Patient Transfer in Mechanical Restraint" (Procedure 249; Revised April 2014) revealed that the main purpose for the use of the Med-Sled is to reduce the risk of injury to staff when moving a patient who is already in restraints.

The policy defines a Med Sled as a "tear resistant vinyl mat." [As observed by Investigator #3, the Med Sled has 3 straps with buckles used to hold the patient in place while staff pull the sled to the desired location.]

There was nothing in the policy about use of the Med Sled for non-restrained patients.

3. Review of a document titled "Preliminary Investigation - update, Alleged Staff to Patient Abuse dated 4/12/2016" revealed the following:

On 3/21/2016 at approximately 10:30 AM Patient #7 was informed by his/her psychiatrist that he/she would be moving from his/her private room to a double occupancy room due to a treatment team decision. Patient #7 refused to cooperate with the room transfer but stated he/she would not be violent. Psychiatric Emergency Response Team (PERT) members and unit staff attempted to talk the patient into transferring to his/her newly assigned room without success. At approximately 2:00 PM, the RN3 (Staff Member #13) and Security Guards (Staff Member #12, #13, #14, #15, #16) moved the patient onto a Med Sled without physical assistance from the patient although the patient was not resisting, and then restrained him/her in the Med Sled. The staff proceeded to move the patient to his/her newly assigned room.

4. An interview with Patient #7 on 4/13/2016 at 11:00 AM revealed that the patient felt that there was no good reason to use force. He/she stated that the use of force was a scary experience for him/her. Patient #7 stated that if staff would have left him alone for a while she/he would have moved on his/her own.

5. Review of Patient #7's medical record confirmed finding #3 above and revealed that there was no psychiatrist order in the medical record for use of the Med Sled, restraint of the patient or forced movement of the patient from a private room to a double occupancy room.

6. An interview with the Director of Forensic Services (Staff Member #18) on 4/13/2016 at 3:00 PM revealed that the use of restraints in this case was being referred for further investigation.
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VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
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Based on observation, interviews, and review of hospital documents and procedures, the hospital failed to train and supervise staff to prevent patient to patient harassment or abuse.

Failure to train and supervise staff to prevent patient to patient harassment or abuse risks patient health and safety.

Findings:

1. Review of the hospital's approved procedure, "Behavior Observation Record" last reviewed 6/2015 read in part, "The Behavior Observation Record is a form used by nursing staff that provides a structured method to observe and assess patients that require specific interventions while being assessed for suicide, self-harm, aggression, or other status that requires observation."

2. Failure to prevent patient to patient assault:
Per review of the hospital's patient to patient assault log from September of 2015 to March of 2016:

a. Patient #2 --Per hospital reports, Patient #2 said she/he was sexually assaulted on 3/23/2016 when she/he slipped away from staff monitors and was found in a bathroom with Patient #3. The patient to patient sexual assault occurred when an institutional counselor staff member who was assigned to monitor Patient #2 on a 1:1, "lost sight" of the alleged victim before discovering the 2 patients in a bathroom.

b. Patient #3--Per the hospital assault log, Patient #3 was involved with 10 patient to patient assaults from 10/19/2015 to 3/23/2016, including the sexual assault with Patient #2. Eight of the incidents were with Patient #10.

c. Patient #8--Per the hospital assault log, Patient #8 (assigned a 1:1 staff monitor) was involved in 9 assaults within a period of 3 weeks, including 4 with injuries from 3/9/2016 to 3/30/2016.

d. Patient #9--Per the hospital assault log, Patient #9 was involved in 7 patient to patient assaults from 9/6/2015 to 1/22/2016.

3. Failure to document clear assignments and staff responsibilities on patient Behavior Observation Records each shift based on patient assessment:

a. Review of the assaulted Patient #2's Behavior Observation Record dated 3/22/2016 for the 0700 to 1400 shift showed no directives identified for the type of observation on the day prior to the incident on 3/23/2016. Review of additional behavioral monitoring sheets revealed inconsistency in the supervisory directives to institutional counselor staff for the kind of monitoring required for patients based on assessment of the patient. For example, on the day of the incident, 3/23/2016, (the Behavior Observation Record for the shift prior to the incident), Behavior Observation record for the 0700 to 1400 shift was marked for "Close" observation-but there was no summary of patient behavior.

b. The investigator noted similar observations of incomplete or unclear nursing documentation and staff directives on patient Behavior Observation Records were noted for Patient #8 and Patient #9.

4. Failure to supervise and train staff to document accurately, and monitor patients to prevent abuse or harassment:

a. Review of documentation showed the institutional counselor (Staff Member #7) who became distracted and "lost site" of Patient #2, filled out the Behavior Observation Record sheet for the shift and falsely documented every 15 minutes that the patient was in "Close" observation the entire time, even when the incident occurred.

b. Interview with the Habilitative Health Care Unit evening Supervisor (Staff Member #17) on 4/13/2016 at 3:00 PM revealed:

c. Patient #2's assigned institutional counselor (Staff Member #7) received a verbal warning following the incident.

d. An email was sent to all staff to reinforce the importance of 1:1 monitoring and accurate documentation in place of actual training and supervision.

e. Interview with patient care staff on 4/13/2016 at 11 a.m. identified the different kinds of monitoring identified as "Close": "Within line of sight" means at all times and document every 15 minutes; and "Constant"- means within arm's length.

5. Interview with Administrative staff on 4/13-14/2016 revealed the 1:1 policy/procedure was in draft form and under review.

The hospital failed to adequately train, assign, and supervise staff to prevent patient to patient assaults.
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VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
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Based on observations, document review, and staff interviews, the hospital failed to ensure the condition of the physical plant and the overall hospital environment was maintained in such a manner that the safety and well-being of patients were protected by:

1. Failure to implement an effective risk reduction strategy for items identified as high risk on the annual Environment of Care physical risk assessment.

2. Failure to conduct effective daily and monthly environmental safety rounds for identification of hazards associated with elopement, ligature, and patient safety.

The cumulative effects of these systemic problems resulted in the hospital's inability to assure a safe and secure physical environment for patients.

Due to the scope and severity of deficiencies cited under 42 CFR 482.41, the Condition of Participation for Physical Environment was NOT MET.

Cross Reference: Tags A0701
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VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
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Based on observations, interview, and document review, the hospital failed to provide an environment that was conducive to the safety of its psychiatric patient population.

Failure to provide a safe environment placed patients at risk of harm to self and or others in the facility.

Reference: National Association of Psychiatric Health Systems "Design Guide for the Built Environment of Behavioral Health Facilities " (edition 6.2, April 2014) Subtitled, "Construction and Materials Considerations", Level 4a. Patient Rooms (page 37):

"It is strongly recommended that all electrical outlets inpatient rooms and patient toilet rooms be hospital grade, tamper-resistant type. It is also preferred that they be GFCI receptacles to greatly reduce the risk of patients being able to harm themselves by tampering with the receptacles."

Item #1 - Ligature, and Patient Safety Risks

Findings:

1. The hospital's Nursing Services Standards manual under the policy titled "PATIENT AND ENVIRONMENTAL SAFETY ROUNDS" (Procedure 204; Date Revised June 2014), read in part: "During change of shift, a staff person from the oncoming shift and the off-going shift are to check on patients and the environment for safety. Items that may constitute a safety hazard include and not limited to: Fire/Electrical hazards, smoking; Unsecure exits, windows and doors; Broken furniture and/or broken glass; Bathroom/shower safety hazards, i.e., water or fluids on floor, and general cleanliness; Blood/body fluids on floor; Potential harmful objects (plastic bags, mop handles, mop wringers, tools, etc.); Unattended custodial/cleaning/maintenance carts; Harmful if ingested Items (Cleaning fluids, Bleach, etc); Furniture or other potential safety hazard items, located in hallways (i.e. Recycle Bins); No Evacuation Plans posted at exit doors; Unlit exit signs; Wheeled office chairs in patient area; Windows covered obstructing the view into and out of a room."

Under the procedure section titled "STEPS" and "KEY POINTS" read in part: "3. Utilizing the Room/Area section on the left hand side of the form observe all areas of the ward accessible to patients. Assess for environmental and physical hazards that may contribute to an unsafe or unhealthy patient environment. Secluded areas on the ward area inviting location for sexual, suicidal, aggressive, predatory activities and smoking. . . 4. Utilizing the Patient and Environmental Safety Rounds Checklist; observe all patient care areas, bathrooms, utility rooms, seclusion, and storage areas noting any physical or psychological changes in patient. If you see an item that needs immediate attention, call x2519. . . 5. Document and report any noteworthy observation to the RN in charge of the ward. 6. Ensure prompt follow-up care if needed".

2. The hospital daily shift "Patient and Environmental Safety Rounds" (Updated 8/18/2015) stated, "Insert finding(s) (numbers/letters) during Patient and Environmental Safety Rounds under time frames. Do not mark if no findings identified ".
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List of findings: 1. Fire/Electrical hazards, smoking within ward. 2 Unsecured exits/windows/doors. 3 Broken furniture and/or broken glass or other unsafe items i.e. DVD etc. 4 Bathroom/showers safety hazards, i.e., hand held shower device, water or fluids on floor, and general cleanliness 5 Blood/ body fluids on floor 6 Potential harmful objects (plastic bags, trash can liners, mop handles, mop wringer, hammers, tools of and kink etc ...) in patient care area. 7 Unattended custodial/cleaning/maintenance carts. 8 Items which may be harmful if ingested. 9 Potential safety hazard items located in hallways (furniture, boxes, recycle Bins, etc) or other items that may contribute to patients falling. 10 Evacuation plans NOT posted at ward exit doors. 11 Unit EXIT signs. 12 Inadequate light in environment, especially night/during emergencies. 12 Inadequate light in environment, especially at night/during emergencies. 13 Uncleanliness, i.e., Improper containment of laundry, trash, and kitchen wastes. 14 Trash, food or beverages in patient rooms. 15 Items staked less than 18 " from ceiling. 16 Laundry chutes obscured/propped open with chairs etc. 17 Unattended wheeled office chairs in patient area. 18 Window covered obstructing view in and out of room. 19 Other: 20 Other:".

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3. On 4/26/2016 between the hours of 10:00 AM and 11:40 AM, Investigator #2 observed a 1 and 1/4 inch construction screw in plain sight on the floor in the seclusion room, room #249 on unit E4.

4. On 4/26/2016 immediately following the observation, Investigator #2 interviewed a registered nurse (Staff Member #2) who stated in part that they had some work done on Sunday. Upon review of the "Patient and Environmental Safety Rounds" for the month of April, there was no documentation to indicate staff observed a screw on the floor of room #249 in unit E4, nor was this seclusion room included on the form as a room to be checked.

5. On 4/26/2016 between the hours of 11:40 AM and 12:20 PM, Investigator #2 toured unit C4 and observed weight bearing hooks attached to window frames. Both the design and location of the attachment posed a ligature risk for patients seeking self harm. The investigator found the hooks in the following areas:

a. Unit C4 Patient Room 114 Weight-bearing hooks on window frame
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b. Unit C4 Patient Room 134 Weight-bearing hooks on window frame
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c. Unit C4 Patient Room 123 Weight-bearing hooks on window frame
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d. Unit C4 Patient Room 131 Weight-bearing hooks on window frame
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e. Unit C4 Patient Room 101 Weight-bearing hooks on window frame
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6. On 4/27/2016 between the hours of 3:00 PM and 3:40 PM, Investigator #2 toured units C3 and C5 and observed weight bearing hooks attached to window frames. Both the design and location of the attachment posed a ligature risk to suicidal patients. The investigator found the hooks in the following areas:

a. Unit C3 Patient Room 336 Weight-bearing hooks on window frame
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b. Unit C3 Bathtub room Weight-bearing hooks on window frame
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c. Unit C3 Patient Room 325 Weight-bearing hooks on window frame
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d. Unit C3 Women's restroom Weight-bearing hooks on window frame
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e. Unit C3 Men's restroom Weight-bearing hooks on window frame
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f. Unit C5 Safe Room 234 Weight-bearing hooks on window frame
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g. Unit C5 Bathtub room 236 Weight-bearing hooks on window frame
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h. Unit C5 Patient Room 238 Weight-bearing hooks on window frame
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i. Unit C5 Women's restroom Weight-bearing hooks on window frame
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j. Unit C5 Men's restroom Weight-bearing hooks on window frame
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k. Unit C5 Seclusion Weight bearing hooks on window frame
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7. On 4/27/2016 between the hours of 3:40 PM and 4:40 PM, Investigator #2 inspected the laundry room on unit S7 and found the following:
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a. A couch and washer/dryer positioned under 11 exposed water lines which poses a ligature risk
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b. A non-tamper resistant electrical outlet in plain sight on the wall above the washer/dryer posed a patient safety risk
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c. Water faucet handles of sufficient length to pose a ligature risk

8. On 4/27/2016 between the hours of 3:40 PM and 4:40 PM, Investigator #2 interviewed a licensed practical nurse (Staff Member #1) about patient supervision in the laundry room. S/he indicated that at times, patients are in the room alone and unsupervised.

9. On 4/28/2016 between the hours of 9:00 AM and 11:00 AM, Investigator #2 inspected two patient rooms and a seclusion room on unit C6 (Rooms # 310, #304, #325) for ligature and patient safety hazards. Investigator #2 observed that patients in these rooms were currently ordered for suicide watch. Investigator #2 found weight-bearing hooks attached to window frames in all of these rooms. Both the design and location of the attachments posed a ligature risk to suicidal patients.

10. On 4/28/2016 at 2:00 PM during document review, Investigator #2 reviewed the hospital's 2015 annual environment of care physical risk assessment inspections. The document indicated that unit S7's laundry room was considered high risk and the action plan to correct the deficiency was to place a work order for remediation.

11. On 4/28/2016 at 2:30 PM, Investigator #2 interviewed the facilities manager (Staff Member #4) about unit S7 laundry room's "High Risk" status, including mitigation of risk while waiting for completion of the work order. Staff Member #4 indicated the risk reduction plan was to have patients supervised whenever they were in the laundry room. Following the interview, on 4/30/2016, the facility staff changed out the locking mechanism for the S7 laundry room to remove access from staff and patients; only one assigned staff member has access to the laundry room.

12. On 4/29/2016 at 11:15 AM, Investigator #4 interviewed the facilities manager (Staff Member #4) to determine how staff communicate the results of the annual hospital physical risk assessment to the hospital executive leadership. Staff Member #4 indicated that the Quality Council receives the report in the 1st quarter of the year. When the investigator asked if the Quality Council had received the 2015 annual physical risk assessment, the staff member confirmed they had not yet presented the results.

Item #2 Elopement

Findings:

1. On 4/26/2016 between the hours of 10:00 AM and 11:40 AM, Investigator #2 inspected a seclusion room, room #249 on unit E4. Investigator #2 observed that the seclusion room had a severely cracked plastic covering over the double pane window. Investigator #2 found similar findings on unit E2 observing a warped protective covering on a rectangular window in patient room A239. A document review of the "Patient and Environmental Safety Rounds" for these units revealed the facility staff failed to identify and document these items as part of their findings.

2. On 4/27/2016 between the hours of 3:00 PM and 5:00 PM, Investigator #2 conducted a physical environment inspection of unit S10 with a mental health technician (Staff Member #3). Upon entering the male patients' restroom, Investigator #2 observed three patients loitering near the window unsupervised. Investigator #2 examined the window and found that the interior glass pane of the double pane window was missing. It was replaced with a thin quarter inch thickness sheet of acrylic plastic that allowed the investigator to insert his/her fingers under and pulled on easily; the plastic sheet was not secured to the window frame posing a potential elopement risk. Staff Member #3 confirmed that the restroom is typically not supervised by staff when in use.
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VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
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Based on observation, the hospital failed to ensure that staff members effectively sanitized equipment required for compliance with the Washington State Retail Food Code (WAC 246-215).

Failure to maintain sanitation protocols places patients at risk for development of foodborne illness.

Reference: Washington State Retail Food Code (WAC)246-215- Equipment-Manual and mechanical warewashing equipment, chemical sanitization-Temperature, pH, concentration, and hardness (2009 FDA Food Code 4-501.114).

Finding:

On 4/29/2016 at 9:00 AM, Investigator #2 observed a plastic chest filled with ice in the break room on unit W1N located in the Habilitative Mental Health (HMH) center. Hospital staff administered ice to patients upon their request. During an interview with the Director of the HMH center (Staff Member #5), s/he confirmed that staff did not sanitize the ice chest on a daily basis as required per Washington State Retail Food Code).
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