Professional Documents
Culture Documents
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.
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
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.
• Action Items
• Resolution
• Participants
• Priority History
• HIPDB Reports
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
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.
Sincerely, ^
Enclosures
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)
Onsitedate: 01 /1 8/1 8
Examination number: 201 7-1 451 9
Intake number: 7771 7
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
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.
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.
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
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
.Was Statement of Deficiencies given to the provider on-site at completion of the survey?.,.. No
TAG/CONCERNS DOCUMENTATION
U -0 0
(ZoV? 0\ '
1 :0 (1
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AIFX O'*— -I "WrO C^LA U -V
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\ ruLxXJwtv-v "
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SEATTLE CHILDREN'S HOSPITAL 2017-14519FS PAGE 11
SURVEYOR NOTES WORKSHEET
TAG/CONCERNS DOCUMENTATION
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
tw a iw It Soitse
keeesslcn Bsay sue
Col lees D m ttUeeted ID
IcsuLce
9. JBSDS looinyxBtatatim
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
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:
•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•
• Keep this notice in the case file when the case is closed.
Notice
ROW 43.701 .075; WAC 246-1 5-01 0; WAC 246-1 5-020(2); and WAC 246-1 5-030.
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^^^
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