You are on page 1of 19

FORM 1 -2-02B

Case Disposition Worksheet

Respondent: , ditdU^ASLt^ Case Number: /-? -/V 5 /9


Date Presented: Profession Section:
Presented by. _ Staff Attorney. Staff present at B/C Disposition:

Pre-Assigned or Requested (circie one)^


SEXU AL MISCON DU CT CASES
For B oard and Commission cases, panel sh ould refer s exual m isconduct cases to the Secretary when there are no clinical Is sues
Involved, pf Is recommended to make this referral only after Investigation; hovrever, any pre-lnvestlgation referral should Include a
panel authorization for investigation.)
• Panel finds there are clinical Issues, do not refer.
• No clinical Issues, refer case to Secretary

Complete Signature Below OnlyIf Case Is Referred to Secretary


Authorized by Panel Chair:
Print Name of Panel Chair:
per Program Staff (Initials) Reviewing Commission Member.
(If applicable) (If applicable)
bate referral authorized:

A. R EQ U ES TER LEGAL ACTION:


• Summary Action:
• Suspension • Practice Resfricf/ons.
• Statement of Charges: • Compliance; Release from STID
• Statement of Allegations: • Compliance:. Release from Order
• Notice of Correction: • Compliance: Referral to Coiiectlon Agency
• Notice of Decision: Grant with • Compliance: Authorization for Fast Track
conditions
• Withdrawal ofSOC: • Withdrawal of SOA:

Alleged Vloiatlon s~RC W 1 8.1 30.1 80:


• (1 ) Moral turpitude • (1 0) Aiding and abetting • (1 9) Treating by secret methods
• (2) Misrepresentation of facts • (1 1 ) Violation of rules • (20) Betrayal of patient priviiege
• (3) False advertising • (1 2) Practice beyond scope • (21 ) Rebating
• (4) Incompetence • (1 3) Misrepresentation or fraud • (22) Interference w/ investigation
• (6) Illegal use of drugs • (1 5) Public health risk • (24) Sexual contact/patient abuse
• (7) Violated state or fed law • (1 6) Unnecessary or inefficacious • (25) Acceptance of more than
drugs nominal gratuity '
• (8) Failure to cooperate . • (1 7) Criminal conviction
• (9) Failure to comply • (1 8) Criminal abortion
O th er Vio la tio n s of Relevan t State or Fed e ral L aw :
Or
ROW 18.130 .170: nMental Irnpaimnent •Physical Impairment

8. FILE CLOSED:
• No Jurisdiction • No violation at the time the • Conduct was within standard
event occuned of practice
• Evidence does not • Risk minima), not likely to • Mistaken Identity
suDDort a violation reoccur .S T ^o violation determined
• Insufficient evidence • Complainant withdrew • No Whistleblower
• Application Investigation • Care rendered was within
Only- No Action to Denv standard of care • Complaint unlaue closure • Statement of Defidencles
=urther explanation (If any •
C. OTH ER. EXPLAIN (Legal Review. Return to investigation, etc.):

Program may request a specific staff attorney who has prior experience with the file or the Respondent.
SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 1
FORM 1 -2-02A
Assessment Worksheet
/M
Respondent: Case Number: 201 7-
Date; 1 1 /30/1 7 Boa iiss dn/Profea§ion; Facillty Type:
, Presented by: Staff present:
I Staff/Panel present: • Board/Commission/CMT meeting
' ISI Peggy O. IS Ramiro C. • Mike E.
IS! Sara K. • Diane S. •
IS Nancy T. • Jon K. •

A. FILE CLOSED:
• BT-No Jurisdiction • BT- No v iolation at the • BT-Communication and • BT- Risk minimal, not
time the event occurred personality Issues likely to reoccur
• BT- Bi lling and fee • BT- Tim e practiced on • BT- Inc ident reported by • BT- If allegations are
disputes except as expired credential accepted by facility true, no violation of law
designated by disciplining disciplining authority occurred
authority
• BT- Pr ofession-specific • BT- Iss ues which have • BT- Referral to another • BT - Insufficient
threshold. been othenvlse resolved. program or agency Information
ExDiaIn: Explain
resolution;
a) Violating confidentiality
b) Inappropriate delegation
c) Failure to supervise
d) Isolated incidents
e) Advertising that Is a
technical violation (detail corrective action:
f) No apparent violation of practitioner Is already revoked;
ongoing monitoring, etc.)
hospital laws.

B. A full investigation of the complaint is authorized.

Date investigation authorized:_

Initiate investigation and obtain relevant records, including patient records.

Additional Instructions to investigator (for example, details for a focused investigation):

Recommended priority: Professions Facilities


• A (risk of immediate danger) ( # of days)
• 8 (serious risk) ( # of days)
• C (moderate risk) ( # of days)
• D (minor risk) ( # of days)
• E (technical violations) ( # of days)
C. SEXU AL M ISCON DU CT CASES

For Board and Commission cases, panel should refer sexual misconduct cases to the Secretary when the case does
not Involve clinical expertise or standard of care issues. (Note: any pre-investlgation referral should still include a
panel authorization for investigation.)
^ • Panel finds there are clinical Issues, do not refer.
• No clinical issues, refer case to Secretary

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 2


%

COMPLAINT INTAKE
SUMMARY WORKSHEET

RESPONDENT INFORMATION
Name& SEATTLE CHILDRENS HOSPITAL Case# 2017-14519(FS)HAC
Address 4800 SAND POINT WAY NE Allegation • Environment. Physical
SEATTLE. WA 98105-3901 • Health and Safety
License # HAC.FS.00000014
Issued -
Expires 1 2/31 /201 8
Phone # Status ACTIVE
Legal Action Yes No Compliance Yes No Cases Open: Closed:
1 1 • • •

COMPLAINANT INFORMATION
Name & UNKNOWN COMPLAINANT
Address
Phone # E-Mail

SUMMARY OF COMPLAINT
The allegations are that there are leaks In the drop ceiling areas of the forest building, and potentially
mold in the HVAC system.

Y:\Conndential\HSQA\LSO\Complainilntake\Facilities -\Case Sumniarics\2017\l 1 - NovembeASeattle Childrens Hospiial\2017-


14S19(FS)HAC.doc

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 3


Case View Screen Page 1 of2

Case View Screen updato


Case 201 7-1 451 9 Date Created 1 1 /20/201 7 Audit
Status OPENED Date Received 1 1 /20/201 7 Entry Items
Respondent ID 851 31 4 How Received Email Documents
Seattle Chiidrens Hospital FACILITIES AND Notes
Respondent Receiving Board
SERVICES Master Cases
HAC.FS.0000001 4 Receiving Profession Hospital /^ te Care License Participants
Credential
Seattle Chiidrens Hospital Receiving Department Case Intake Add Master Case
Address Received By Joe J. Johnston Timeline History
O Public ® Mail
Alleged Issues
Seattle Chiidrens Hospital Environment. Physical
Attn; Lisa Brandenburg Health and Safety
PC Box 5371 Case Nature
M/S RB.2.41 9 Public Health Safety or Wblfare
SeatUe.WA 981 45-5005
Complainant ID 967751
Complainant Unknown Complainant
Comments:

• Action Items
• Resolution
• Participants
• Priority History
• HIPDB Reports

Action Items add add group


Type Assigned To Activity Track Time Due Effective Completed Order Signed Created •
No action items found

http://elicense/caseView.asp?CaseIdnt=285870 11/20/2017 PAGE 4


SEATTLE CHILDREN'S HOSPITAL 2017-14519FS
Credential View Screen Page 1 o f3

Credential View Screen entity tree

Seattle Chlldrens Hospital ID 851314 Contact


Warnings CASE PENDING Audit
Address:
SSN/FEIN Enforcemc
O Public Mail Federal ID 91 0564748 Cont. Edu
Document
Seattle Childrens Hospital Secretary Of StatoNumber 1780 19356
Owners
Attn; Lisa Brandenburg Contact Standing In-Business
Owned By
PO Box 5371 Contact Type NGN PROFIT CORPORATION Exams
M/S RB.2.419 Public File YES Experience
Seattle. WA 98145-5005 Mailing List Notes
US Citizen Schools
Web Address www.seattlechildrens.org Librarian
Application
Comments: Other Stat€
Online Info
Reports

H ospital Acute Care License form letter

HAC.FS.00000014 Credential Status ACTIVE (1 0/03/201 7) Audit


Credential 9
Document
Legacy License # 000008 Status Reason ACTIVE
Verification
Application Date Amount Due $0.00 Workflow
Effective Date 01 /01 /201 6 Date Last Activity 11 /8/201 71 2:40:20 PM Key Mgmt
Expiration Date 1 2/31 /201 8 Last Updated by Sauceda. Stephen S Fees
First Issuance Date Certificate Sent Date 10 /03/2017 Notes
Last Date Of Contact Print Docs
Next Examinations Date 11/27/2017 Comp. Aud
Renewal
Comments: License Renewal Cards Requested to be sent ATTN: Lisa Brandenburg Legacy
License 81
Online Infc
• Supervises
• User Defined License Data
• Workflow
• Legacy

Supervises update Show All

http://e!icense/credView.asp?credidnt=874244 1 1 /20/201 7
SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 5
STATE OF WASHINGTON
DEPARTMENT OF HEALTH

January 25, 201 8

Jeff Sperling, Administrator


Children's Hospital & Regional Medical Center
Po Box 5371
Seattle, WA 981 05-0371

Re; Investigation #WA0007771 7 / Case #201 7-1 451 9

Dear Jeff Sperring:

This letter informs you of the outcome of the completed complaint investigation
conducted on January 1 8, 201 8. After reviewing the complaint investigation, we
determined there were no deficiencies pertinent to this complaint under WAC
and/or 42 CFR regulations.

Enclosed is your copy of the Statement of No Deficiencies. If you have any


questions regarding the process or results of this investigation you may contact
our office at 360-236-4681 . Please include the investigation number of the
facility.

Sincerely, ^

Frank Schitoskey, Manager


Office of Investigations and Inspections
P.O. Box 47874
Olympia, WA 98504-7874

Enclosures

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 6


PRINTED; 01 /25/201 8
FORM APPROVED
state of Washington
STATEMENT OP DEFICIENCIES (XI) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED

C
000008 B. WING 01 /1 8/201 8
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS. CITY. STATE, ZIP CODE
4800 SAND POINT WAY NE, PO BOX C-5371
SEATTLE CHILDREN'S HOSPITAL
SEATTLE, WA 9 81 05
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5»
PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE DATE
DEFICIENCY)

B 000 Initial Comments 8000

STATE COMPLAINT INVESTIGATION

The Washington State Department of Health


(DOM) In accordance with Washington
Administrative Code (WAC), Chapter 246-320
WAC Hospital Licensing Regulations, conducted
this health and safety complaint investigation.

Onsitedate: 01 /1 8/1 8
Examination number: 201 7-1 451 9
Intake number: 7771 7

The investigation was conducted by:


Lisa Mahoney, MPH, PHA

There were no violations pertinent to this


complaint.

state Form 2567


LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X8)DATE

STATE FORM KEJ81 1 II continuation sheet i or 1

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 7


DOH/HSQA
Complaint Investigation Form
For Adm in Use Only
F a cility; Seattle Childrens Hospital State Investigation IEI
Location; Seattle, WA Medicare Investigationn
License #: 0000001 4 Investigator(s):Investigator
Shell #: KEJ81 1 Lisa Mahoney
ILRS #: 201 7-1 451 9
ACTS #: 7771 7

Onsite Date: 01 /1 8/201 8 Exit 01 /1 8/1 8 Admin Review Admin Review


Start Date: Exit Date:
Date:
Deficiencies: Yes n No Kl
SOD Sent: POO Received: POC
Approved:
Onsite 1"'
Revisit Date:
Onsite 2"** -
Revisit Date:
Email Sent 1 /1 9/1 8 Working Papers to 1 /1 9/1 8
to Manager: Manager:

Packet 1 Survey
( Packet) Packet 2 (Notes Packet)
Q Signed 2567 form _| Marcia Cook
_ Approved Plan of Correction 1 1 Mary Wood
IXI 670 form 1 1 Lisa Sassi
^ Signed CMS 25678 form 1 1 Rosie Tillotson
Follow-up CMS 670 form 1 1 Deborah Barrette
[2 Confidential List |~ Diane Sanders ,
1 3 Investigative Report I5?l 1—
|_J Applicable correspondence-
- SOD/No SOD Letter/POC Approval Letter
- Emails exchanged with facility,CMS,etc
IF APPLICABLE
_ | Fire Marshal 2567

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 8


Investigative Renort
On-Sitc State and/or Federal Investigation

Facility: Seattle Children's Hospital


Location: Seattle, WA
License Number: 00000014
Medicare Number:
State Case Number: 2017-14519
ACTS#: 77717
Shell#: KEJSn
Dates of Investigation; 01/18/2018
Investigator: Lisa Mahoney

Allegations— The complainant alleges:


1. Water leaks in drop down ceiling areas in the "Forest" building within the hospital
2. Ongoing issue with mold in HVAC system due to continued water leaks

Process: The investigative process included the following:


The investigator interviewed facility staff regarding complaint. The interviewees included the
Regional Operations and Maintenance Director, the Construction Oversight Manager and the
Facilities Construction and Maintenance Manager. The investigator reviewed the ICRA with the
hospital's infection control staff and toured the area where the leak had occurred. The investigator
reviewed air-sampling records for evidence of ongoing contamination in the area of the leak.

Summarv of Findings: The staff acknowledged they had identified a water leak in the "Forest
building" Emergency Department during environmental rounds in November 2017, They
immediately notified the Infection Control Department, who initiated an infection control risk
assessment (ICRA) for the mitigation of the leak. Subsequent investigation by hospital staff
determined a failing valve above the drop ceiling in the hospital caused the leak. They contracted an
industrial hygienist to examine all valves in the hospital for similar leaks, and have mitigated any
additional areas of water leaks. They also conducted air-sampling tests after the leak w ^ stopped to
ensure that there was no evidence of ongoing contamination.

Conclusion: The allegation that the hospital had a water leak in the "Forest Building" was
substantiated but corrected at the time of the investigation. The allegation that there was an ongoing
issue with mold was not substantiated.

Action: Statement of No Defieieneies issued

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 9


DEPARTMENT OF i lEALTM AND HUMAN SEP
CENTERS FOR MEDICARE & MEDICAID SEl S FORM APPROVED

SURVEY TEAM COMPOSITION AND WORKLOAD REPORT

Public reporting burden fbr this colleciion ofinromuiion is estimated to average 1 0 minutes pet response, including time for rev iewing instructions, searching existing data sources, gathering and
mamtaining data needed, and oomplcimg and reviewing the c ollcctioH ofrnfanmition. Se nd comments regarding this burden eiiimaie or arty other aspect of this collcctinn ofinformation,
including suggestions for reducing the burden, to OfTicc ofFinancial Management, HCFA, P.O. Box 266M, Baltimore, MO 21 207; or to t he GITice of Management and Budget. Paperwork
Keduction Projcct(0838-0S83), Washington, D.C. 20503.

Provider/Supplier Number Provider/Supplier Name


S03300 SEATTLE CHILDREN'S HOSPITAL

Type of Survey (seleci all thai apply) A Complaint Investigation E Initial Certification 1 Reccriiflcation
B Dumping Investigation F Inspection of Core J Sanctions/Hearing
C Federal Monitoring G Validation K State License
D Follow-up Visit H Life Safety Code L CHOW
M Other

Iixtcnt ofSui^ey (select all that apply) A Routine/Standard Survey (all providers/suppliers)
B Extended Survey (HHA or Long Term Care Facility)
H TTT C Partial Extended Survey (HHA)
D Other Survey

SURVEY TEAM AND WORKLOAD DATA


Please enter the woifcload inrormation for each surveyor. U se the surveyor^ ideniincation number.

Surveyor ID Number First IJBt Pr^Survcy On«Site On-Site On-Siie Tnivd OfT-Sitc Report
(A) Date Date Preparation Hours Hours Hours Hours Preparation
Arrived Dqurtcd Hours 12am-8am 8am-6pm 6pm-l2am Hours
(B) (C) (D ) (E) (F) (G) (H ) (1 )

Team Leader ID
1. 31 31 2 01 /1 8/201 8 01 /1 8/201 8 1.50 0.00 1.50 0,00 3.00 2.00

1 0.
11.
1 2.
1 3.
1 4.
Total SA Supervisory Review Hours. Total RO Supervisory Review Hours,...
0.00 0,00

Total SA Clerical/Data Entry Hours,.., Total RO Clerical/Data Entry Hours,


0,00 0.00

.Was Statement of Deficiencies given to the provider on-site at completion of the survey?.,.. No

FORM CMS-670 (1 2-91 ) EventlD; K j^jgn FoclliiylD: 000008 Page 1


SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 10
DEPARTMENT OF HEALTH AND HUMAN SERV
rcMTPRS FOR MEDICARE ft MEDICAID S ERVIC

SURVEYOR NOTES WORKSHEET


Facility Name: CA^ Surveyor Name: _
Provider Number:. Surveyor Number:. Discipiine:.

TAG/CONCERNS DOCUMENTATION

U -0 0

(ZoV? 0\ '

1 :0 (1
^ )
? D ' . 1 cXj_Wtl-LL J

.0 u ) ri A Jx-. •
Lt> PVKA-C« ku r \
t^f r m
^ d c L -t ^
K b lcA . ^ A
AIFX O'*— -I "WrO C^LA U -V
*-v/3 W

L A L - /r\ V J UL^ — P /) i ^ S c J /i . ( ^
1 VV^SJ,CAO< u-ixXoA
\ ruLxXJwtv-v "
V
U- uJLl-/ 5^"—

0^ VjUk/^ ?
) ,. V

'p.O IOTZA^S 4 1 ^ 4K - ieA^% C^KJ^.


Jp. V>—
i
C/? KiAz-tX<J LA^JUSA^ /\A ^

u-^o
SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 11
SURVEYOR NOTES WORKSHEET
TAG/CONCERNS DOCUMENTATION

Form CMS-807 (07/95)

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 12


INFECTION PREVENTION CONSTRUCTION MONITOR

CLASS II
Location of Construction: Wall above ED exam room 47 & 48 doors
Project Coordinator: Doug Mason Start Date: 1 1 /3/1 7
Contractor: Sellen Estimated Duration: 25 days
Telephone: x71 218 Completion Date: 1 1 /28/1 7
TYPE OF CONSTRUCTION ACTIVITY INFECTION CONTROL RISK GROUP
TYPE A GROUP 1
X TYPEB X GROUP 2
TYPEC GROUP 3

Description of Work:
Repair of leaking pipe above celling, dry or cut out and replace sheetrock above exam
room 47 and 48 doors.

Class II Requirements:
1 . Tape over wet wall section until barriers can be placed
2. Place a barriers prior to beginning the work (or use Green Machine for above
ceiling work)
3. Maintain negative pressure within the worksite by one of the following methods:
a. Using a HEPA-filtered negative air machine and exhausting air to the
exterior of the building (recommended)
b. Exhausting air away from the construction area using a supply air diffuser.
In this case, carpet^ard floors in the area of the exhaust plume should be
vacuumed/mopped immediately prior to turning on the negative air
machine.
c. Placing a portable HEPA filter unit inside the tent if neither of the above
methods are possible
4. Monitor negative pressure within the construction site by the use of manometer.
5. Seal unused doors with tape.
6. Execute work by methods that minimize raising dust from construction activities.
7. Contain construction waste before transporting in tightly covered containers and
transport via a route that avoids public or inpatient areas of the hospital.
8. Wet mop with hospital disinfectant and/or HEPA vacuum at the completion of the
work. Or have the area cleaned thoroughly by Environmental Services.
9. At least 2 hours after the cleaning is completed, air test both inside barriers
and outside the ED.
1 0. After air test results received from Infection Prevention, remove barrier materials
carefully to minimize spreading dirt and debris associated with construction.
Additional Requirements: Air Sampling? QN

W6H7
Infection Preventionlst Date

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 13


MKBD, IRGDS 1004093/&i9U.CUtlai 12/1C/15 U :06
/96 yean 2 mochs/OnkiafloCecclao Gaicrel, Qegnlsatto
QC/gc/QC

MQC JLxgus b v ln n Air Oatdoon, ED U/M/17 16:56


17-Ue-ia94 U/14/17 16:56
11/14/17 16:45
FinalK 11 ColOBy Rm lflg Dnica Baccerla
4 GDlmy Fd aiao Qhita Ibc A^ergiUua , Thne Cblosy lypea

eyU AI XBfeecia C mol ItopBR Mge:

NOUBae IVpa tee ItolMloB


aaea/aae/9n IstcadlBg FiovtAt J ttls b u vM ile
Ideitlo n

tw a iw It Soitse
keeesslcn Bsay sue
Col lees D m ttUeeted ID
IcsuLce

9. JBSDS looinyxBtatatim

MQC IrgiB U /I4 A 7 11:11


i7 >u a> i9 a U/1 4A7 16:99
11/14/17 U:4C
naol 9 CblMV FoolB D Bttsa DeeeerU

NO: JUguj D BeetD 46 U A4/1 7 17:60


lT -3ie-UM U/1 4A7 17:00
tl/1 4 A 7 U:«T
riM i 1 teloqr n m n g (kUa B m e s ii
2 Q iloqr F n la g QiUa lla g u Bis tapetalUH

t m s i a / I e u fe e B m Blassar
Date Id cetu a
iy i6 /1 9 23:99 QC/OVge
iy i6 /1 9 23:91 OC/QC/QC
lyio/is 23:» oe/oe/ee

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 14


Prtnt«d: 12/1 2/2017 Intake Number: WA00077717
Due Date: 01/26 /2018 INTAKE INFORMATION Facility ID: 000008
Priority: Non-IJ Medium Provider Numt>er: 503300

PROVIDER IN FORM ATION :


Name: SEATTLE CHILDREN'S HOSPITAL License#: 0000001 4
Address: 4800 SAND POINT WAY NE. PO BOX C-5371 Type: HOSP-CHD
CIty/State/Zlp/County: SEATTLE, WA. 981 05, KING Medicaid#:
Telephone: (206) 987-2000 Administrator: JEFF SPERRING
IN TAKE INFORM ATION :
Intake Number: WA0007771 7 Received Start: 1 2/1 2/201 7 At 1 0:40
Taken by - Staff: VAJDA, VALERIE Received End; 1 2/1 2/201 7 At 1 0:40
Location Received: DOH FSL HHHACS Received by: E-Mail
Intake lype: Complaint State Complaint ID; 201 7-1 451 9
Intake Subtype: State-only, licensure CIS NumlMr:
SA Contact: SANDERS, DIANE External Control #:
VAJDA, VALERIE
RO Contact:
Responsible Team:
Source: Anonymous

C OM PLAIN AN TS:
Name Address etiscs. ififiiiL
Not Applicable
Link ID: 02UIWZ
Confidentiality Requested:

IN TAKE DETAIL:
Date of Alleged Event: Time: Shift:
Standard Notes: The allegations are that there are leaks in the drop celling areas of the forest building, and potentially mold In the
HVAC system.
Extended RO Notes:
Extended CO Notes:
ALLEGATION S:
Category': Physical Environment
Sul>-catesory:
Seriousness:
Details:

' D EEM ED/RO APPROVAL IN FORM ATION : ^


Ro Request for Approval: RO Approval Date:
SU RVEY IN FORM ATION :
Event ID Start Date Exit Date Team Memtiers
KEJ81 1 1 2/1 2/1 7 01 /24/1 8 MAHONEV. LISA
AC TIVITIES:
Type SSQS Due Completed Responsible Staff Member
Schedule Onsite Visit 1 2/1 2/201 7 1 2/1 2/201 7 01 /24/201 8 MAHONEY, USA

Reason for Restraint;


Cause of Death;

END OF INTAKE INFORMATION

ACTS: lntal(e.rpt 10/99 Page 1 of l

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 15


InvBBfioatfon Wo^heet

•Cato Number;
fnvesfigafiionlVPQ^ . Prioi1ty;i
. Allegations
Accidents • other Services
^AdrninisfratlonyPersonnel • Pharmaceutical Services ^
Admission, Tlansfsr & Discharge ^ Physical Erivironment
'.'Rfghfs .
3 Death - General ' . P Physician-Services
Denfel Services Quality of Care/Treatment
Dietary Services".- "Quair^ofLtfe •" ' .
Educ^onaJ Services Rehabilitation Gervdces
• Emil^ (Patieht Dumping) •Resldent/Patient/GIient Abuse
FalsHrcation of Records/Reports Residorlt/PatiBnt/Client As^sment
Faiality/Transfusipn Fatality. Resldent/PalienffCllent Neglect'
FifaudyFalseBflling • • ResMent/P^ntfG]leifit.Rlghts
Infection Control Respinfe/Seciuslon-Death -
Injury of Unknown Orfeln . Resnialnte/Secltision - General
LRie Safety Code- State Licensure ' .
IWIsappro^atlon of Property • Slate Monltoiing • •
Nucsli^ Services Unquailfied.Personne!
mother • . ' '
Conditions of Participation
• nYesnNo . ' . •
Hospitals
Anesthesia Services Nursing Services . • '
Discharge Planning Organ, Tissue, &.EyB ProGurement
EinergerHy Services ; Outpatient Services
Fatal Trahsfuslorr-Ruction. Patient Rights ' " ? .--i
Fecjeral State and Local Laws Pharmaceutical Services
fdod and Dietetic Services Physical Environment •"
(SoVeminaBocfy •. Quality Assurance"
IrrtfecBon Control • • Radiological Services- -.
LaiDoiatory Services Rehabilitation Services
LSC Respiratory Carp Services
Wedicel Record Services • "Surgical Sendees *
i/ledlcal Staff Utilization Review . -
• Nuclear Medicine Services
Investigation Details
' fnyestigaflonNuinben \ . Due Date;- 2 U -\8 '
Twd for RO AppiWal:
InvesflgatoR-./^ ^>4* ~ I•

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 16


%

Department of Health staff need to:


. Place this notice in the case file.

• Keep this notice in the case file when the case is closed.

Notice

A whistleblower is "a consumer, employee, or health care professional who


reports quality of care concerns to the department of health." WAC 246-1 5-
01 0(9). An Individual's Identity as a complainant Is kept confidential except
for release "to appropriate department staff or disciplining authority
members, in response to a court order, or If the com plaint is not made In
good faith." WAC 246-1 5-020 and 246-1 5-030. However, if a
whistleblower plays some other role in the complaint—as a witness for
example—his or her identity may be disclosed. A notice that the complaint
was made by a whistleblower will be placed and remain in the department's
complaint file.

ROW 43.701 .075; WAC 246-1 5-01 0; WAC 246-1 5-020(2); and WAC 246-1 5-030.

DO N OT REMOVE FROM FILE


SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 17
York, Brian P (DOH)
1 - Name - Whistleblower Regarding Health Care Provide...
From:
Sent: Monday, November 20, 201 7 3:1 9 AM
To: DOH HSQA Complaint Intake
Subject: Facility Complaint

Hello,

1 want to'remain anonymous because I am employed at Seattle Children's Hospital. I want to report an
unsafe facility condition. The hospital recently contracted a company to fix leaks across the five year old
Forest building. The company had to seal the areas due to mold. There is a potential the mold is in the
HVAC system. There are reports of leaks in the drop ceiling areas. The Forest building homes the Pediatric
and Cardiac ICUs, Cancer Care Unit, and Emergency Department. I would like the health department to
investigate the building and make sure it is safe for employees, patients and fa milies.

Thank you.

'^ECE/VED I
m 2 0 2017 I
°^^!fl.9'^'-EGALSERWCFe '
(COMPLAINT INTAKE^^^

SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 18


Case File_1256892_pdf-r.pdf redacted on: 7/30/2019 10:23

Redaction Summary ( 1 redaction )

1 Privilege / Exemption reason used:

1 -- "Name - Whistleblower Regarding Health Care Provider or Health Care Facility - RCW 43.70.075(1), RCW 42.56.070(1)"
( 1 instance )

Redacted pages:

Page 18, Name - Whistleblower Regarding Health Care Provider or Health Care Facility - RCW 43.70.075(1), RCW
42.56.070(1), 1 instance

Page 1

Related Interests