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.

WELLFOUND BEHAVIORAL HEALTH HOSPITAL 3402 S 19TH ST TACOMA, WA April 7, 2020
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0175
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Based on record review, interview, and review of the hospital's policies and procedures, the hospital failed to ensure that staff members followed the hospital's seclusion policy and procedure for documentation in 1 of 3 seclusion records reviewed (Patient #301).

Failure to follow established policies and procedures places patients at risk of physical and psychological harm and possible violation of patient rights.

Findings included:

1. Document review of the hospital's policy titled, "Use of Seclusion and Restraint," no policy number, approved 10/19, showed that staff will assess the patient for readiness to discontinue seclusion at regular intervals to ensure the patient's safety. The intervals between assessments should not be longer than 15 minutes.

2. On 04/03/20 at 8:30 AM, Investigator #3 and the Chief Nursing Officer (Staff #301) reviewed the medical records of three patients who were placed in seclusion during their hospitalization . The review showed that Patient #301 was placed in seclusion for kicking and banging on walls at 11:23 AM on 03/16/20. The patient was released from seclusion on 03/16/20 at 2:25 PM. The review showed no documentation on the seclusion observation monitoring flowsheet to indicate that staff members had assessed the patient from 1:45 PM until 2:25 PM, a period of 40 minutes.

3. At the time of the record review, the Chief Nursing Officer (Staff #301) acknowledged that no documentation could be found for that period of time.
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VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
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Based on record review, interview, and review of hospital policy and procedures, hospital staff failed to provide accurate documentation of administered medications in the hospital's electronic Medication Administration Record (eMAR) for 2 of 5 patient records reviewed (Patients #302, #303).

Failure to provide accurate documentation in the eMAR, of the medications patients received risks medication errors and patient harm.

Findings included:

1. Document review of the hospital policy and procedure titled, "Medication Administration and Documentation: General Guidelines," no policy number, approved 10/19, showed that the licensed staff member who administers the medication shall record the administration in the patient's electronic medication administration record (eMAR) after the medication is given. It also showed that staff should document the time, route, and any other specific information as necessary.

2. On 04/02/20, Investigator #3, the Chief Nursing Officer (CNO) (Staff #301), and the Director of Quality (Staff #302) reviewed the electronic medication administration records (eMARs) of five patients. The review showed:

a. Patient #302 was to receive Chlorpromazine 25 mg (an antipsychotic medication) daily at 8:30 AM. The eMAR on 03/30/20 showed the patient received the medication at 9:27 AM and 11:48 AM. Similarly, the patient was scheduled to receive Baclofen 20 mg (a muscle relaxant medication) at 1:30 PM. The eMAR on 03/30/20 showed that the patient received this medication at 1:25 PM, and again at 1:41 PM.

b. Patient #303 was to receive Sertraline 200 mg (an antidepressant medication) daily at 12:00 PM. The eMAR on 03/27/20 showed the patient received the medication at 12:03 PM and 12:05 PM.

3. On 04/02/20 between 11:00 AM and 3:00 PM, Investigator #3 interviewed the CNO (Staff #301) and the Pharmacist in Charge (PIC) (Staff #303) about the multiple documented entries identified in the eMARs of Patient #302 and #303 for medications administered around a scheduled time. The PIC (Staff #303) provided documentation from the Pyxis machine (automated dispensing system) which showed that the nurse retrieved the selected medications only once from the Pyxis during those time periods. The investigator asked how the duplicate entries in the eMAR occurred. The CNO stated that the issue appears to be a staff training/knowledge problem with the use of the medication administration barcoding system.