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.

UNIVERSITY OF WASHINGTON MEDICAL CTR 1959 NE PACIFIC ST BOX 356151 SEATTLE, WA 98195 June 17, 2018
VIOLATION: QUALIFIED PERSONNEL Tag No: A0818
Based on interview, review of medical records and review of hospital policy, it was determined that the hospital failed to assure that appropriately qualified personnel developed or supervised the development of, discharge plans for an 5 of 10 patients whose medical records were reviewed. The hospital's failure to do so placed some discharged patients at risk for unmet discharge planning needs.

Findings include:
On May 31, 2018 at 3:30 PM, the Manager stated that sometimes nursing staff was responsible for implementing the discharge plan for patients who had post-discharge oxygen needs and documenting same; and that sometimes the implementation and documentation of the plan was the responsibility of Respiratory Services staff. The Manager confirmed that guidance regarding which discipline was responsible for the initiation, and the documentation of the initiation, was not contained in any policies and procedures.

Review of 10 medical records, which were reviewed with the Manager, revealed that some medical records had missing documentation, and some medical records contained documentation from RT, while others contained documentation from the nursing staff.

Reference Citation at Tag A0820
VIOLATION: IMPLEMENTATION OF A DISCHARGE PLAN Tag No: A0820
Based on interview, review of medical records and review of hospital policy, it was determined that the hospital failed to assure that appropriately qualified personnel developed or supervised the development of, discharge plans for an 5 of 10 patients whose medical records were reviewed. The hospital's failure to do so placed some discharged patients at risk for unmet discharge planning needs.

Findings include:

On May 31, 2018, at 11:00 AM, the Manager of Respiratory Services stated that sometimes Respiratory Therapy (RT) personnel were responsible for the initiation of the discharge plan of care regarding oxygen and oxygen equipment, and sometimes the nursing staff were responsible for the initiation of the discharge plan of care for post--discharge oxygen needs.

The Manager confirmed that guidance regarding which discipline was responsible for the initiation, and the documentation of the initiation, was not contained in any policies and procedures.

Review of 10 medical records, which were reviewed with the Manager, revealed that some medical records had missing documentation, and some medical records contained documentation from RT, while others contained documentation from the nursing staff.

Patient #1
The medical record did not contain documentation from nursing personnel regarding initiation of the plan of correction. Documentation from RT noted that there had been a "set up", but did not specifically state that an oxygen tank had been provided. The RT Manager confirmed the findings, and confirmed that the term "set up" was not clear as to what had been done for the patient, or what supplies had been provided.
The medical record did contain documentation that the physician had ordered home oxygen.

Patient #2
The medical record did not contain documentation from RT staff. The medical record did contain documentation that the physician had ordered oxygen.

Patient #3
The medical record contained documentation on the day before discharge, that RT staff had contacted a company regarding the patient's need for post-discharge oxygen. RT also documented that the company would send staff to the hospital "...tonight or in the morning for the home oxygen set up..."
Documentation from nursing, on the day of discharge, noted that the patient had "left with travel oxygen on 2L. Planned to contact [company] representative on ride home to coordinate set up in home."

Patient #5
No documentation was found in the medical record. The lack of documentation was confirmed by the Manager, who stated that s/he would expect documentation regarding implementation of the patient's discharge plan to be incorporated into the medical record.

Patient #6
No documentation was found in the medical record. The lack of documentation was confirmed by the Manager, who stated that s/he would expect documentation regarding implementation of the patient's discharge plan to be incorporated into the medical record.

All medical records were reviewed, and discussed with, the Manager of Respiratory Services and the Director of Social Work & Care Coordination.

Reference Citation at Tag A0818