Providence St. Peter Hospital must submit a report documenting how it will correct deficiencies that were found after a joint state and federal investigation of an unexpected death of a patient on February 3.
The death that triggered the investigation and a "statement of deficiencies," was of a 63-year-old man admitted to Providence St. Peter Hospital's chemical dependency center to withdrawal from alcohol.
The investigation of the patient's death was conducted by both the state Department of Health and the federal Center for Medicare & Medicaid Services.
The investigation of the patient's death was first reported Friday by the Puget Sound Business Journal. On Monday, a spokesman at the Washington Department of Health provided a copy of the DOH's and the federal CMS's "statement of deficiencies" generated by the patient's death to The Olympian.
DOH spokesman Donn Moyer said the DOH investigation was spurred after Providence St. Peter Hospital's own mandatory self-reporting of the patient's unexpected death.
The statement of deficiencies found that Providence St. Peter Hospital staff did not follow a physician's orders on monitoring the patient's vital signs.
"On interview and document review, requirement of vital signs every three hours on admission, and then every shift was not followed for this patient," reads the statement of deficiencies.
The investigation also found that the physician's orders required that he or she be notified if the patient's blood pressure fell below a certain level, "and this did not happen."
A physician told an investigator that at the chemical dependency center "there are only two nurses for 40 patients" so "the patients are required to come to the nursing desk for vital signs and the nurses do not seek out the patients at time intervals," reads the statement of deficiencies. "This was not confirmed by three nurses."
Moyer said the practice of investigators writing a "statement of deficiencies" after an unexpected patient death is unusual. Thurston County Coroner Gary Warnock said Monday that the man's Feb. 3 death is the first one he can recall at Providence St. Peter Hospital's chemical dependency center.
Moyer said the statement of deficiencies was provided to Providence St. Peter Hospital, and additionally to he Seattle branch of the Center for Medicare & Medicaid Services.
Officials with the Center for Medicare and Medicaid & Medicaid Services, in both Washington D.C. and Seattle, could not be reached for comment Monday to discuss whether its funding to Providence St. Peter Hospital could potentially be impacted by the DOH statement of deficiencies.
Providence St. Peter Hospital has until April 10 to submit to DOH its plan for corrective action, Moyer said.
Deborah Shawver, a spokeswoman for Providence St. Peter Hospital released a brief statement to The Olympian Monday.
"This is a very difficult situation and we have the utmost compassion for the family and their loss," Shawver wrote. "Patient safety is our first priority and, while the cause of death has not been determined, whenever there is an unexpected patient death we take the situation very seriously."
Shawver added that "we have immediately taken steps to respond to all survey findings and continue to conduct reviews and develop responsive plans. We are fully committed to a quick and complete resolution and partnering with DOH on any and all outstanding issues. DOH will then conduct a follow-up survey in the future."
Jeremy Pawloski: 360-754-5445; firstname.lastname@example.org