IDENTIFICATION NUMBER: Administrative Code (WAC),

PRINTED: 08/05/2019FORM APPROVEDState of WashingtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:60429197(X2» MULTIPLE CONSTRUCT!ON07/26/2019B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING:IDPREFIXTAGL 420 Continued From page 5L 420L 420 322-040,1 ADMIN-ADOPT POLICIESL 420PROVIDER'S PU\N OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)WAC 246-322-040 Governing Body andAdministration. The governing bodyshall: (1) Adopt written policiesconcerning the purposes, operation andmaintenance of the hospital, and thesafety, care and treatment ofpatients;This Washington Administrative Code is not metas evidenced by:Based on interview, medical record review, andreview of the hospital's policies and procedures,the hospital failed to assure that policies andprocedures were reviewed and revised to reflectcurrent clinical practice.Failure to review and revise policies to reflectcurrent practice prevents the hospital staff fromcarrying out all of the functions of the organizationand risks unsafe, inconsistent patient care.Findings included:1. Record review of the hospital's policy andprocedure titled, "Policies and Procedures," policy#ADIV1.P.500 reviewed 05/19, showed that thehospital will have policies and procedures in placethat will reflect evidence-based practice andguide staff to carry out all of the functions of thehospital to promote safe, consistent, high-qualitycare.a. Record review of the hospital's policy andprocedure titled, "Diabetes: Patient Care," policy#PC.D.200 reviewed 02/19, showed that staff willtreat a blood sugar level below 70 by following thehypoglycemia protocol and staff will not withholdscheduled insulin doses. For treatment of high orState Form 2567STATE FORMNGVJ11If continuation sheet 6 of 20

PRINTED: 08/05/2019FORM APPROVEDState of WashinqtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:COMPLETED07/26/2019B. WING60429197NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA.WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4» IDPREFIXTAG(X3) DATE SURVEY(X2) MULTIPLE CONSTRUCTIONA. BUILDING:L 420 Continued From page 6IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L 420low blood sugar levels, staff will foilow physicianorders and/or Cascade Behavioral Hospitalnursing procedure.b. Record review of the hospital's pharmacypolicy and procedure titled, "IntravenousTherapy," policy #MM.05.01.07 reviewed 05/18,showed that the hospital offers no intravenoustherapy services (no IV solutions or supplies) anda home health agency will administer allintravenous medication on site.2. Review of Patient #1 001 's medical record on07/24/19 at 1:25 PM, showed a pre-printed ordersheet to guide staff on the treatment of thepatient's blood glucose levels. Review of theorder form showed it was labeled with thepatient's ID stamp and a hand written noteshowing orders were faxed to pharmacy. The topof the form showed orders for monitoring thepatient's blood glucose (before meals & atbedtime), showed Regimen #1 and #2 guidelinesfor supplemental insulin according to the currentpatient's blood glucose level, and the bottom ofthe form showed the hypoglycemia protocol.The hypoglycemia protocol provides steps thatstaff will follow to treat a diabetic patient with ablood glucose level 70mg/dl and includestreatment for a patient who is conscious ortreatment for a patient who is unconscious. Fortreatment of an unconscious patient with a bloodglucose of 50-69mg/dl, staff will administer 25mlof D50W intravenous and repeat a blood glucoselevel in 15 minutes.Review of the Patient #1001's blood glucoselevels showed an average level of 170-200 andhe was administered Humalog insulin accordingto Regimen #2 guidelines.State Form 2567STATE FORMNGVJ11If continuation sheet 7 of 20

PRINTED: 08/05/2019FORM APPROVEDState ofWashinfitonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:B. WING6042919707/26/2019NAME OF PROVfDER OR SUPPLIERSTREET ADDRESS. CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKW1LA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETED(X2) MULTIPLE CONSTRUCTIONA. BUILDING:L 420 Continued From page 7IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L 4203. During an interview on 07/24/19 at 2:00 PM,the Chief Nursing Officer [CNO] (Staff #1002)confirmed that the hospital does not provide staffsupplies or medications to administer medicationintravenously. The CNO was asked how staffcould follow the hypoglycemia protocol for Patient#1001 if the hospital does not provide intravenousservices. The CNO stated that if the patient'sblood glucose level reaches a critical point andbecomes unconscious, then staff are to call 911.4. During an interview on 07/25/19 at 1:00 PM,the hospital's Pharmacist (Staff #1003) reviewedPatient #1001's blood glucose order form andrevealed that the form's approval date (showed inthe footer) was 05/18. The Pharmacist alsostated that the hospital does not stock D50Wintravenous solutions and it is not available. Hestated that the pre-printed blood glucose orderform will need to be reviewed and revised by theP & T committee.L715 322-100.1E INFECT CONTROL-PROVISIONSL715WAC 246-322-100 Infection Control.The licensee shall: (1) Establish andimplement an effective hospital-wideinfection control program, whichincludes at a minimum: (f) Provisionsfor: (i) Providing consultationregarding patient care practices,equipment and supplies which mayinfluence the risk of infection;(ii) Providing consultation regardingappropriate procedures and productsfor cleaning, disinfecting andsterilizing; (iii) Providing infectionState Form 2567STATE FORMNGVJ11If continuation sheet 8 of 20

PRINTED: 08/05/2019FORM APPROVEDState of WashinatonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTfON(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTIONB. WING6042919707/26/2019NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA, BUILDING:L715 Continued From page 8IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L715control information for orientationancf in-service education for staffproviding direct patient care; (iv)Making recommendations, consistentwith federal, state, and locallaws and rules, for methods of safeand sanitary disposal of: (A)Sewage; (B) Solid and liquid wastes;and (C) Infectious wastes includingsafe management of sharps;This Washington Administrative Code is not metas evidenced by:Based on observation, interview, and documentreview, the hospital failed to implement aneffective procedure to monitor the physicalenvironment for situations that support the growthof microorganisms that could spread infectiousdisease.Failure to prevent the growth and spread ofwaterborne pathogens places patients, staff, andvisitors at risk for infections.Reference: CDC Legionelia Toolkit, Developing aWater Management Program to ReduceLegionella Growth & Spread in Buildings; APractical Guide to Implementing IndustryStandards, updated 05/15/17. Elements of aneffective water management program includeidentification of areas where water could pool andstagnate, apply and monitor control measures,establish corrective actions to intervene whencontrols are not met, evaluate the program'seffectiveness, and document the activities.Findings included:1. Document review of the hospital's policy titled,"Water Management Plan," Policy #F.WMP. 100State Form 2567STATE FORMNGVJ11If continuation sheet 9 of 20

PRINTED; 08/05/2019FORM APPROVEDState of WashinatonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTIONB. WING6042919707/26/2019NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING;L715 Continued From page 9IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L715approved 11/18, showed that ice/water dispenserdrain lines are not identified as areas where watercould pool and stagnate; control measures/limits,including elimination of stagnant water andmonitoring disinfectant levels are not identified;corrective actions do not address equipmentdrain lines; and the verification process(evaluation) refers to semiannual testing withoutidentifying testing protocols.Document review of Follett Symphony series Iceand Water Dispensers Installation, Operation andService Manual showed that drains must maintainat least 1/4-inch per foot of slope on horizontalruns.2. During the survey, Surveyor #6 made thefollowing observations of 6 ice/water dispensers:a. On 07/23/19 at 2:00 PM, Surveyor #6 touredUnit 2-W with the Chief Nursing Officer (CNO)(Staff #603). Surveyor #6 observed a Follettbrand Symphony series ice/water dispenser in thedining room. The lce/water dispenser's drain lineran horizontally with a dip that allowed water topool. The drain line did not maintain the requiredslope.b. On 07/24/19 at 10:10 AM, Surveyor #6 touredthe hospital's kitchen and cafeteria with theDietary Director (Staff #609). Surveyor #6observed a Hoshizaki brand ice/water dispenserwith a clear PVC (polyvinyi chloride) drain hosethat rested horizontally across the flat surface of acabinet for a length of approximately 2-feet. Thedrain hose showed significant black slimeaccumulation indicating bacterial growth.c. On 07/24/19 at 10:55 AM, Surveyor #6 touredUnit 2-N with the Nurse Manager (Staff #609).State Form 2567STATE FORMNGVJ11if continuation sheet 10 of 20

PRINTED; 08/05/2019FORM APPROVEDState of'WashinqtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTIONB. WING6042919707/26/2019NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTtFYING INFORMATION)(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING:L715 Continued From page 10IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L715Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the Day Room. Theice/water dispenser's drain line ran horizontallywith a dip that allowed water to pool. The drainline did not maintain the required slope.d. On 07/25/19 at 10:50 AM, Surveyor #6 touredUnit 3-N with the Nurse Manager (Staff #610) andthe Director of Facilities (Staff #606). Surveyor #6observed a Follett brand Symphony seriesice/water dispenser in the Clean Utility room. Theice/water dispenser's drain line ran through anopening in the countertop and was not visible.Staff #606 stated that special tools were requiredto access the space below the countertop andthat the drain line installation was the same asother countertop ice/water dispensers. Staff #606stated he did not know whether the drain linemaintained the required slope.e. On 07/25/19 at 11:30 AM, Surveyor #6 touredUnit 3-W with the Nurse Manager (Staff #611)and the Director of Facilities (Staff #606).Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the pantry for thedining room. The ice/water dispenser's drain lineran through an opening in the countertop and wasnot visible. Staff #606 stated that special toolswere required to access the space below thecountertop and that the drain line installation wasthe same as other countertop ice/waterdispensers. Staff #606 stated he did not knowwhether the drain line maintained the requiredslope.f. On 07/25/19 at 11:45 AM, Surveyor #6 touredUnit 4-W with the Nurse Manager (Staff #611)and the Director of Facilities (Staff #606).Surveyor #6 observed a Follett brand Symphonyseries ice/water dispenser in the Clean UtilityState Form 2567STATE FORMNGVJ11If continuation sheet 11 of 20

PRINTED: 08/05/2019FORM APPROVEDState ofWashinfltonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:60429197(X2) MULTIPLE CONSTRUCTION(X3) DATE SURVEYCOMPLETEDA. BUILDING:B. WING07/26/2019NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY, STATE, ZIP CODECASCAOH B.HAVIOR HOSPITAL :S S:D SOUTHSUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)(X4) IDPREFIXTAGL715 Continued From page 11PROVIDER'S PLAN OF CORRECTIONIDPREFIXTAG(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATEDEFICIENCY)(X5)COMPLETEDATEL715room. The ice/water dispenser's drip tray was fullof water (not draining). The drain line ran throughan opening in the countertop and was not visible.Staff #606 stated that special tools were requiredto access the space below the countertop andthat the drain line installation was the same asother ice/water dispensers. Staff #606 stated hedid not know whether the drain line maintainedthe required slope.L 815 322-120.7 MAINTENANCE P&PL815WAC 246-322-120 Physical EnvironmentThe licensee shall: (7) Implementcurrent, written policies, procedures,and schedules for maintenance andhousekeeping functions;This Washington Administrative Code is not metas evidenced by:Based on observation, document review, andinterview, the hospital failed to ensure that staffmembers properly performed housekeepingfunctions, including failure to maintain a cleanenvironment (1), failure to maintain environmentalsurfaces in smooth, non-absorbent, and easilycleanable condition (2), and failure to adequatelyand effectively disinfect environmental surfaces inpatient rooms (3).Failure to properly perform housekeepingfunctions places patients, staff, and visitors at riskof increased exposure to allergens and harmfulmlcroorganisms.Findings included:Item #1 - Clean environmentState Form 2567STATE FORMNGVJ11If continuation sheet 12 of 20

PRINTED: 08/05/2019FORM APPROVEDState ofWashinqtonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:60429197(X2) MULTIPLE CONSTRUCTION07/26/2019B. WINGNAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168SUMMARY STATEMENT OF DEFICIENCIES(X4) ID(EACH DEFICIENCY MUST BE PRECEDED BY FULLPREFIXREGULATORY OR LSC IDENTIFYING INFORMATION)TAG(X3) DATE SURVEYCOMPLETEDA. BUILDING:L 815 Continued From page 12IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE e: Guidelines for EnvironmentalInfection Control in Health-Care Facilities.Recommendations from CDC and the HealthcareInfection Control Practices Advisory Committee(HICPAC), 2003; updated July 2019. Pg. 147. ERecommendations - Environmental Services;subsection E. Keep housekeeping surfaces (e.g.,floors, walls, and tabletops) visibly clean on aregular basis and clean up spills promptly.1. Document review of the hospital's policy titled,"Belongings (Patient)," policy #PC.B.100reviewed 02/19, showed that the hospital shouldprovide for safe and appropriate management ofpatients' personal belongings.Document review of the hospital's documenttitled, "Quick Reference: EnvironmentalCleaning," revised 10/17, showed that equipmentwith visibly soiled surfaces should be scrubbedwith a cleaner/detergent or disinfectant.2. On 07/23/19 from 10:50 AM to 3:10 PM,Surveyor #6 toured patient care areas with theChief Nursing Officer (CNO) (Staff #603). Theobservations showed unclean areas, excessiveamounts of dirt, dust, and debris, and items/areaswhose readiness for use could not bedetermined;a. Room #103 (used for video court) - patientcare equipment that could not be identified asclean or disinfected, or whether it had been used:a wheelchair, a disposable, cone-style face maskhanging from a push handle of the wheelchair, 2sets of cloth restraints lying on the seat of thewheelchair, 2 Ambu disposable face masksloose in a drawer.b. Assessment Room #4 (used for medicalA/italState Form 2567STATE FORMNGVJ11If continuation sheet 13 of 20

PRINTED: 08/05/2019FORM APPROVEDState of WashinfltonSTATEMENT OF DEFICIENCIESAND PLAN OF CORRECTION(X1) PROVIDER/SUPPLIER/CLIAIDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTIONB. WING6042919707/26/2019NAME OF PROVIDER OR SUPPLIERSTREET ADDRESS, CITY, STATE, ZIP CODECASCADE BEHAVIORAL HOSPITAL12844 MILITARY ROAD SOUTHTUKWILA,WA 98168(X4) IDPREFIXTAG(X3) DATE SURVEYCOMPLETEDA. BUILDING:SUMMARY STATEMENT OF DEFICIENCIES(EACH DEFICIENCY MUST BE PRECEDED BY FULLREGULATORY OR LSC IDENTIFYING INFORMATION)L815 Continued From page 13IDPREFIXTAGPROVIDER'S PLAN OF CORRECTION(EACH CORRECTIVE ACTION SHOULD BECROSS-REFERENCED TO THE APPROPRIATE(X5)COMPLETEDATEDEFICIENCY)L815signs assessment) - no sanitizer/disinfectantwasavailable for sanitizing patient care items afteruse. There was no indicator that informed staffwhether the room was ready for use.c. Assessment Room #2 " contained soiledclothing and discarded paper products. Therewas no indicator that informed staff whether theroom was ready for use.d. Patient Belongings Storage (Room 4 in the "oldsurgical suite") - over-flowing garbage bin, trashon the floor throughout the room, disorganizedstorage of patient belongings on the floor andshelves intermingled with debris.e. Soiled Utility on Unit 2-W - stained surfaceunder the sink, dirt & debris along floor coving.f. An OfficeA/isitation Room on Unit 2-W - dirt &debris on the floor.3. On 07/23/19 at 11:15 AM. Surveyor #6interviewed Staff #603 and a Milieu Specialist(Staff #605) about the patient care items listed inRoom #103. Staff #605 stated that the wheelchairshould have been disinfected after patient use,but that she did not know whether that had beendone. Staff #605 stated she did not know of apolicy or procedure to launder cloth restraints,and that they might have been used up to 5 timesin the past year without being cleaned or sanitizedafter patient use. Staff #603 stated that theAmbu bags were probably left over from aprevious hospital facility.4. On 07/24/19 from 10:40 AM to 1:45 PM,Surveyor #6 toured patient care areas with theDirector of Risk & Quality (Staff #601). Theobservation showed unclean areas andState Form 2567STATE FORMNGVJ11If continuation sheet 14 of 20

PRINTED: 08/05/2019FORM APPROVEDState of WashinqtonSTATEMENT OF

daily Emergency Crash Cart Equipment Checklist. Failure to verify the correct serial-numbered lock on the emergency cart could result in a cart without the supplies listed within that could risk potential delays In providing emergency care. Findings included: 1. Review of the hospital's policy and proce