Patient safety lapses found at Tacoma hospital opened in ’19 to address mental health crisis
State officials investigating a whistleblower complaint at a new Tacoma behavioral health hospital found the facility did not have clear admissions standards, which could have jeopardized patient safety.
During an investigation into the facility conducted Dec. 2 and 3, the state Department of Health found Wellfound Behavioral Health Hospital failed to have a policy in place that specified the process for reviewing and admitting patients who had been declined admission by another medical provider at the facility, according to documents obtained by The News Tribune through a public records request.
The investigation also found that — in one of seven patient files reviewed — Wellfound had failed to document patient physical examinations and admission histories within 24 hours of being admitted to the hospital.
The deficiencies put Wellfound patients at risk for having unmet medical needs, investigators found.
It marked the fourth time state investigators identified problems at Wellfound last year, documents show.
The investigation at Wellfound was authorized after the Department of Health received a whistleblower complaint in November, according to records. The whistleblower alleged non-medical senior officials at Wellfound Behavioral Health Hospital, including CEO Matt Crockett, had “overridden internal medical providers’ decisions” to decline patients admission to the hospital, the documents reveal.
According to Department of Health spokesperson Gordon MacCracken, the whistleblower complaint also led to an unlicensed practice investigation into Crockett, which is separate from DOH investigation that found fault with the hospital’s admission policy.
Since that case is still under investigation, DOH officials are unable to comment on it, MacCracken said.
“People … have the opportunity to defend themselves, as is true in any disciplinary action,” MacCracken said. It’s possible that no wrongdoing by Crockett will be found, he noted.
The News Tribune has requested documents related to the open unlicensed practice investigation into Crockett, who did not respond to a request for comment made by The News Tribune.
Wellfound also declined an interview request from the paper. MultiCare chief communications officer Marce Edwards Olson responded with a statement on the hospital’s behalf.
In the statement, Wellfound said it was “committed to addressing the vital behavioral health needs in our region and takes seriously the responsibilities we have to provide the high-quality, safe and compassionate mental health care our patients, families and communities deserve.”
The hospital welcomes “regulating agencies’ review of our policies and practices,” the statement said. “Key to our care and treatment is our continuous effort to refine processes and procedures and make system refinements.”
After presenting Wellfound with the investigation’s findings Dec. 17, the state required Wellfound to submit a plan of correction, which was approved by the Department of Health six days later. As part of the hospital’s corrective measures, Wellfound developed a new specific policy related to patient admissions and pledged to conduct regular reviews of patient charts and admission decisions, records show.
A review of the hospital’s compliance is now scheduled for March, according to documents.
The whistleblower’s allegations against Wellfound and Crockett are similar to issues identified as part of a 2018 DOH facility investigation at Smokey Point Behavioral Hospital in Marysville, where the CEO was previously employed.
As The Seattle Times’ Daniel Gilbert reported in “Public Crisis, Private Toll,” Crockett, who has no medical license, was known to “weigh in on which patients to admit” during his time as CEO at Smokey Point, which is run by a national firm with a history of acquiring struggling hospitals and turning a profit.
Unlike the December facility investigation into Wellfound, the 2018 investigation into Smokey Point did not directly result in a separate unlicensed provider case against Crockett, MacCracken said.
According to Mike Sweeney, a retired Boeing employee and former BECU chair who now serves as chair of the Wellfound Board of Directors, the hospital informed the board of the department of health investigation in early December.
Sweeney said he wasn’t concerned to learn about the investigation but said there’s always room for improvement.
“Concerned? No. Can we do better? Yes,” Sweeney said. “I think we need to continue to strive to make it better.”
Sweeney also said that the board was informed that two Wellfound employees, including Crockett, had been placed on administrative leave during the investigation.
Wellfound confirmed that two employees had been placed on leave while the investigation was reviewed but declined to identify them, describing it as a personnel matter. The hospital also would not say if placing an employee on administrative leave was standard operating procedure during an investigation. Both employees have returned to work, the hospital said.
Sweeney said he believes Wellfound handled the investigation appropriately and that he had full confidence in Crockett’s leadership.
“He’s very thoughtful. He’s developed a very good leadership team,” Sweeney said of Crockett.
“I think he’s done a very, very good job.”
Admitting patients with ‘complex medical needs’
Like previous visits to Wellfound, records related to the December 2020 visit to the hospital show that investigators observed the facility’s patient care units, conducted interviews with administrative staff and medical providers and reviewed hospital documents and policy.
Under Wellfound hospital policy there are times when patients with “complex medical needs” can be declined admission, investigators noted. For instance, patients with specific oxygen needs or those weighing more than 350 pounds can be excluded from admission and referred elsewhere. In some cases the decision to decline admission of a patient by one medical provider at the hospital can be reviewed and changed, the documents show.
According to an investigative report summary of findings, that process is where state investigators identified deficiencies at the hospital. The lack of clear policy and procedures could have led to a patient being admitted that the hospital couldn’t safely care for, they found.
Wellfound’s “policy did not specify who was responsible and involved in making the decision to admit patients that may have some more complex medical needs,” the investigators determined.
“Staff interviewed voiced confusion about the process for patients that required a second review to determine if the hospital could meet the patient’s needs. Staff stated that if a medical provider denied admission, the administrative staff would have another medical provider review the patient information,” the summary of findings indicated.
“The concern was the process with the second review did not involve the medical provider doing the second review to consult with the original provider as to why the patient was originally declined admission,” investigators wrote.
Interviews conducted by the Department of Health during the course of the agency’s investigation provide evidence for the agency’s findings, documents show.
According to the Department of Health investigation report, a licensed clinical social worker at the hospital “stated that on several occasions a patient would be denied admission for medical reasons by one provider only to be admitted by another provider.”
A physician assistant at Wellfound told investigators that “if a patient was denied admission by one medical provider the administration would ask another medical provider to review the patient information.” The physician assistant also indicated that “the reviewing medical provider did not always consult with the first provider as to why the patient was denied admission initially,” according to documents.
During an interview with state investigators, Crockett said Wellfound’s administration would “review patients declined for admission with another medical provider to determine if the patient’s needs could be met,” according to the investigators’ report. Crockett also told investigators “the reviewing provider did not always consult with the provider that declined the admission originally,” the DOH report states.
According to notes taken during Crockett’s interview, the Wellfound CEO told investigators he wasn’t “qualified” to make admission decisions at the hospital. The notes indicate that Crockett told investigators, “I will ask why the patient cannot be admitted, but the MD makes the decision not me.”
In Wellfound’s statement to The News Tribune, the hospital acknowledged “DOH found that Wellfound’s admission policies did not adequately address the criteria for admission and any medical assessment prior to admission.”
“Wellfound thoroughly reviewed policies to make the recommended improvements, and we are confident that this situation has been addressed,” the statement said.
Asked about the severity of findings against Wellfound as a result of the December investigation, Department of Health spokesperson Shannon Walker declined to comment, describing this as “a value judgment we can’t make.”
“Our mission is to ensure patient safety, so if specific circumstances warrant a statement of deficiencies, we’ll issue one and work to see that the facility puts a plan of correction into effect,” Walker said.
“We take any potential violation seriously.”
Multiple state investigations in 2020
When Department of Health investigators arrived at Wellfound in early December, it marked the sixth time the agency had conducted an investigation at the facility in 2020, according to Walker.
Department of health investigations vary, Walker said, and they don’t always result in findings of deficiency. An allegation from May that hospital staff had been instructed not to report and document patient-on-patient assaults was ultimately found to be unsubstantiated, records show. At least one other investigation in 2020 was closed with no violation determined, Walker said.
In addition to the Department of Health’s December investigation into Wellfound, three other investigations during 2020 did result in findings of deficiency at the facility, records indicate.
In April, investigators concluded that Wellfound staff failed to properly document administered medication and the observation of at least one patient placed in seclusion.
In July, state investigators determined the hospital had failed to follow through on “policies for assessing and reassessing patients who are victims of physical assault while hospitalized” and implement its Code Gray Policy, which is used in hospital settings to call for security personnel.
During an investigation completed in October, department of health investigators found that Wellfound failed to protect a patient’s right to be free of sexual harassment, according to documents obtained by The News Tribune but not publicly available online.
In that case, investigators reviewed 40 documented instances of assault or aggression at the hospital. Six were found to be “sexual in nature.” In one instance, two patients were found having sexual intercourse, an encounter the hospital documented as “consensual,” according to documents. Both patients were on involuntary 14-day psychiatric holds.
Wellfound has submitted approved plans of correction in all three cases, documents show.
According to Walker, investigation at licensed psychiatric hospitals aren’t uncommon. The Department of Health conducts each investigation “individually in accord with the laws and rules that govern our work,” Walker said.
Licensed psychiatric hospitals like Wellfound that provide involuntary court-ordered services in Washington, like 14-day holds, also must have a behavioral health agency license. Psychiatric hospital license rules focus on operational standards such as construction, staffing and infection control, while behavioral health agency licensing rules regulate the particular services provided at the facility, Walker said.
“Depending on the nature of the complaint, there could be potential violations of the psychiatric hospital rules, the behavioral health agency licensing rules, or both,” Walker said.
At Washington’s 11 facilities, there were a total of 68 psychiatric hospital license complaints authorized for investigation in 2020, according to department of health records provided to The News Tribune.
Forty behavioral health agency license complaints were authorized for investigation at these facilities, the documents show.
Only operating 60 beds
Unveiled in May 2019 as a joint venture between CHI Franciscan and MultiCare, the $41 million nonprofit hospital benefited from the support of local elected officials and millions in public money, under the promise that the facility would provide 120 desperately needed mental health beds in Pierce County once it was fully open.
In 2017, Pierce County had roughly 2.8 psychiatric beds per 100,000 residents, while King County had 27.1 beds per 100,000 residents.
According to the hospital’s website, Wellfound is designed to provide “partial hospitalization and inpatient mental health treatment in Tacoma.”
When the hospital opened, a Multicare press release noted that the facility would “provide voluntary and involuntary admissions with a focus on general adult psychiatric care for ages 18 and older with common psychiatric conditions such as acute depression, suicidal tendencies, self-injury, mania, psychosis and anxiety.”
Wellfound’s long-awaited opening was marked by administrative turnover, tragedy, regulatory challenges and delays.
Crockett took over at Wellfound after the hospital’s first CEO, Maureen Womack departed in June 2019, one month after the facility celebrated its grand opening. The hospital declined to give a reason for Womack’s exit.
In July 2019, Kevan Carter Jr., who was declined admission to Wellfound twice in a 24-hour period, stepped in front of a train near his childhood home of Titlow Beach, taking his own life. Shortly after The News Tribune reported on Carter’s death, the hospital temporarily halted admissions.
That same year, multiple Department of Health investigations into the hospital — including one launched in response to Carter’s death — identified roughly 70 pages of deficiencies at the facility, many of them potentially serious.
As The News Tribune also has reported, the hospital struggled to secure important Joint Commission safety accreditation, which among other things allows the hospital to bill Medicaid and Medicare. The hospital announced it had achieved Joint Commission accreditation in December 2019. At the time, the 120-bed hospital indicated that it planned to be “fully operational” by the end of 2020.
That has yet to happen.
Currently, Wellfound is operating just 60 beds, with an average census ranging between 50 and 60 patients a day, according to the hospital. Hiring enough employees to expand the facility during the coronavirus has been a challenge, the hospital indicated.
There are “plans to increase to 84 in the coming months,” the hospital told The News Tribune.
This story was originally published January 28, 2021 at 5:00 AM with the headline "Patient safety lapses found at Tacoma hospital opened in ’19 to address mental health crisis."
