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 98498 March 10, 2016
VIOLATION: GOVERNING BODY Tag No: A0043
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Based on interview and review of medical records, hospital documents and policies and procedures it was determined the hospital failed to assure the Condition of Participation for Governing Body. The Governing Body failed to implement systems and processes to address the nutritional needs of patients.

Failure to ensure a process was implemented to identify significant changes in weight placed all patients at risk for deterioration in condition.

Findings include:

During the exit meeting the hospital leadership, to include the Director of Nursing Services and Interim Director of Nursing Services, confirmed there were problems with the hospital practice of documenting, tracking and monitoring patients wieghts.
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VIOLATION: NURSING SERVICES Tag No: A0385
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

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Based on observation, interview and document review of hospital policies and procedures, the hospital failed to ensure that Nursing staff implemented approved policies and procedures addressing patient assessment and implementing treatment for changes in weight. Failure to ensure policies and procedures were implemented for 3 of 10 patients (#s 1, 2 & 3) resulted in harm to 1 of 3 patients (#1) who had a significant weight loss.



Findings include:



1. According to PROCEDURE: Medical Nutrition Therapy Algorithm (WSH 23-40), there are two levels of triggers (criteria for nutrition assessment). Level I trigger may occur when a patient is first admitted to the hospital. On admission the patient receives a nursing assessment. Problems that would trigger a nutrition consult include, gastrointestinal problems, renal problems, hepatic problems, diabetes, pregnancy, a significant weight loss (5% of body weight in the past month, a special diet, refusal or inability to eat due to a physical problem or a delusional problem.

Level II Triggers may occur once a patient had been admitted and more information has been gathered. After admission height, weight, Body Mass Index (BMI) and lab values are obtained. These data may generate a referral to the dietitian.

The dietitian routinely completes nutrition evaluation, follow-up and patient education. The dietitian will chart this follow-up in the progress notes. If the patient's nutritional status changes or worsens the patient will be reassessed and additional referral will be sent to the dietitian.

The Nursing Services Standards Manual Protocol 334 MANAGEMENT OF THE PATIENT WITH WEIGHT INSTABILITY included areas of responsibility for Registered Nurses (RNs). The Care Directives included "Assess/compare current weight or recommended body weight with baseline weight taken on admission/transfer and/or recommended body weight. Patients' weights are to be assessed over the past months to determine if weight loss/gain identifies a pattern. If there is an identified weight loss/gain of 5% from the patients' baseline weight within a month or 7.5% in three months or 10% in six months the RN is to notify the Medical Doctor and contact the dietitian for nutritional assessment and dietary consult when significant weight change is documented. The RNs are to document assessment and reassessment, the patients' response to interventions and treatment plan. The RN is also responsible for the documentation of vital signs and weight record flowsheet and treatment plan.

The Nursing Services Standards Manual Procedure 232 for HEIGHT, WEIGHT and ROUTINE VITAL SIGNS includes direction to Licensed Nurses and Certified Staff to obtain a height, weight and vital signs within the first 8 hours of the admission and documented on the admission nursing assessment form. If the patient refuses vital signs, follow up attempts are to be made up to three times. If the patient refuses, following the third attempt, the Medical Doctor is to be contacted for orders as to how to proceed.

Weight and vital signs are taken routinely on every patient during the first week of each month; day shift and evening shift nursing staff develop a process to equally divide assignments to ensure every patients' weight in Cache Web, and day and evening shift are responsible for entering the vital signs data on the Vital Signs/Daily Care Flowsheet.

2. Patient #1 (former patient) was admitted to the hospital in October 2014 with diagnoses of multi-system chronic medical conditions, mental health disorder, difficulty swallowing and malnutrition. The patient had delusions about food and at times would only eat oatmeal. On admission, the patient weighed 118 pounds at 5 feet 9 inches. The patient ' s Body Mass Index (BMI) was 16 (normal 18.5 to 25). According to a nutritional assessment completed on 10/8/2014, the patient's ideal body weight should be 157 pounds.

On 12/06/2015 Patient #1 weighed 126 pounds. No weight for Patient #1 was found in the record for January 2014. On 2/2/2015 the patient weighed 121.6 pounds. No weights were obtained in March, April or May 2015. On 6/2/2015 the patient weighed 108.6 pounds.

Physician orders were written on 6/2/2015 to obtain weekly weights for 8 weeks. One weight was obtained on 6/26/2015, the patient weighed 104.6 pounds. The patient had a 17% weight loss between 2/2/2015 and 6/26/2015 No assessment for nutritional status was completed.

On 6/24/2015 a physician wrote an order to track the patient's meal consumption for 5 days. Review of the progress notes, behavior observation notes and intake and output summary reports lacked completed entries for each meal.

On 7/2/2015 (31 days after the hospital had identified a significant weight loss) a nutritional assessment was completed. It was documented the patient had a 24.4 pound weight loss.

On 7/20/2015 the patient weighed 97.8 pounds. No subsequent weights were obtained or documented.

On 7/22/2015 an order for tube feedings was written and to monitor the intake and output and weekly weights. No documentation for the patient's weight was found in the record.

On 8/5/2015 the MD wrote an order to discontinue the IV and "encourage intake."

On 8/6/2015 the patient fell and was transported to a hospital for evaluation and treatment of a fractured hip. The patient died on [DATE].


3. Patient #2 was admitted to the hospital in February 2010 with diagnoses of mental health disorders. The patient had a history of not eating.

Observation of the patient during breakfast on 3/4/2016 at 8:30 a.m. revealed he ate alone in the common area of the unit. He frequently stood up while eating. Staff would cue the patient to eat.

The patient had an initial physician order written 8/5/2013 for obtaining weekly weights.

Review of the Daily Care Flowsheet indicated the patient weighed 157.2 pounds on 9/5/2015. On 12/19/2015 the patient weighed 146 pounds (11.2 pound weight loss in 3 months or a 7.85% weight loss). There were no weights documented on the flowsheet for October or November 2015 or January 2016. On 2/6/2016 the patient weighed 141 pounds.

Review of the PATIENTS CURRENTLY BEING MONITORED FOR WEIGHT LOSS report revealed Patient #2 was not on the list for monitoring weights.


4. Patient #3 was admitted to the hospital in April 2015. His initial weight was 241 pounds. The next reported weight of 295 pounds was on 9/2/2015.

On 1/2/2016 an order was written to monitor the patient's weight weekly. There were no documented weights for January 2016.

On 1/20/2016 the patient was transferred to a hospital with signs and symptoms of shortness of breath and swollen legs. The patient was treated for a blood clot in a lung. The patient was returned to the hospital. The patient's record did not include subsequent weights since returning from the hospital.