Matt Driscoll

Suicide, whistleblower complaint prompt investigations at Tacoma psychiatric hospital

After months of public scrutiny, Tacoma’s new psychiatric facility — Wellfound Behavioral Health Hospital — had good news to report in December, at long last.

The $41 million hospital, a partnership between local health care giants MultiCare and CHI Franciscan, finally achieved accreditation through the independent nonprofit Joint Commission.

Securing the important safety accreditation, according to Wellfound, was one of the last hurdles the hospital needed to clear before it could deliver on its delayed promise to Tacoma and Pierce County: 120 psychiatric beds in a community desperate for them.

But documents recently obtained by The News Tribune through a public records request show questions about Wellfound remain.

In particular, the state Department of Health documents show there are two open investigations into the hospital. The agency also recently confirmed a third.

Based on a review of those documents — roughly 750 pages dating back to last year and depicting the early stages of the investigations — it’s unclear what has transpired since.

Remaining questions include deficiencies formally identified by Department of Health investigators as well as the scope and nature of any corrective actions taken by the hospital.

Beyond confirming their existence, the Department of Health declined to elaborate on the three ongoing investigations, though the two longest-running open cases date back to August, documents show.

On Aug. 12, the health department began looking into the suicide death of Kevan Carter. Jr.

The following day, the department initiated an investigation related to a separate complaint filed anonymously by a whistleblower at the hospital.

The whistleblower complaint alleges Wellfound was accepting patients on 23-hour holds without the proper license.

The most recent investigation dates to a complaint the Department of Health received in November, according to the state agency. Citing the ongoing and open nature of the case, the health department declined to offer further details, instead directing The News Tribune to file an additional public records request.

Health department officials did say all three open investigations relate to possible violations of state hospital laws.

Asked about the three investigations, Wellfound officials declined a request for an interview.

In a statement provided to The News Tribune via email, the hospital said, “Operating a facility like ours often includes multiple visits by the Department of Health (DOH) and other surveyors, including The Joint Commission.”

“We have welcomed these thorough visits, which are typical for a new behavioral health hospital and are a critical part of our mission to fill a major regional behavioral health need,” the statement added.

Wellfound said that findings identified by the Department of Health during the investigations have been “typical in scope and number for a new behavioral health hospital.”

To date, the hospital said, any necessary changes have been “implemented quickly.”

Suicide prompts investigation

According to the documents, on Aug. 9 the state health department received a complaint about the death of 29-year-old Kevan Carter Jr.

As The News Tribune reported, Carter Jr. had a history of mental health issues and, last July, sought care at the hospital twice in a 24-hour period.

Carter Jr. was sent home each time and ultimately stepped in front of a moving train near his childhood home of Titlow Beach on the morning of July 23, taking his own life.

The News Tribune’s article on Carter’s death, which first appeared online Aug. 9, is included in the complaint.

Shortly after the article, Wellfound placed a temporary hold on admissions to its crisis stabilization unit.

At the time of Carter Jr.’s suicide, Wellfound had been open and operating, on a limited basis, for two months. Prior to opening last year, it had been championed by a host of local elected officials and built with the help of millions of dollars in local taxpayers’ money.

The death prompted Carter Jr’s mother, Bedez Carter, to tell The News Tribune that she was “not convinced that Wellfound is ready to handle this.”

“My main thing is they sent him away twice, within 12 hours, twice in one day, for a man walking in and saying I need help,” Bedez Carter told the newspaper last year.

Anonymous whistleblower complaint

The second open investigation into Wellfound, according to the documents, was spurred by a whistleblower complaint filed by an employee of the hospital.

According to a Department of Health summary of the complaint, it alleges that Wellfound was holding “patients on 23-hour observations without the proper licensing.”

“Facility staff was told verbally but nothing in writing, and continue to perform this service,” the complaint summary continues, adding that the “facility allegedly lacks the bed and bathroom as defined in WAC’s to keep patients overnight.”

According to the documents, the complaint was received on Aug. 13.

It was reviewed and authorized for investigation the following day.

“The second complaint was not expedited because of the other investigation, but because of the allegations,” according to a statement provided by Kristen Maki, a department of health spokesperson.

In addition to concerns about licensing and hospital amenities, the whistleblower’s complaint claimed Wellfound had experienced “several” recent elopements and one “sentinel event.”

“I’m really nervous about if I’m operating outside of what I should be doing licensure wise,” a written transcript of the whistleblower complaint states.

“I wish this to be anonymous because my department will terminate me. I guarantee you they will use some other reason but they will terminate me. They’re very tight lipped right now,” the statement continues.

“We’re not allowed to talk about anything.”

‘We spend as much time as necessary’

The third open investigation into Wellfound was not part of The News Tribune’s initial records request.

The paper learned of the investigation during the course of reporting.

According to a Department of Health spokesperson, it was initiated by a complaint received on Nov. 25, 2019, and authorized the same day.

Health department officials said the information they could provide was limited since the investigation is open and ongoing.

The department also could not provide an estimate of when the three investigations would be completed, noting that “the time it takes to complete an investigation will vary depending on the nature of the complaint and the complexity of the case.”

Like the other two open investigations, the department would say that the most recent also relates to the possible violation of state hospital laws.

“Investigations may take as little as a few weeks or, in some cases, up to six months or more,” the department’s statement said.

“We spend as much time as necessary to thoroughly investigate each complaint.”

Six complaints, three investigations

According to department statements provided by Maki and Gordon McCracken, another Department of Health spokesperson, investigations vary widely, as do their causes.

Every investigation is different, the officials added, noting that not all complaints warrant an investigation.

That’s been true in Wellfound’s case.

According to the Department of Health, while three complaints against Wellfound have triggered investigations, three more complaints against the hospital failed to meet the agency’s threshold.

Wellfound celebrated its opening May. 9, 2019.

From July 1, 2018 through June 30, 2019, the state health department received 93 total complaints regarding Washington’s 11 psychiatric hospitals.

Forty were authorized for investigation, according to the agency.

In 2019, the agency said, roughly 42 percent of complaints triggered investigations.

Describing investigation protocol, the health department’s statement indicated that once an investigation is authorized, “the department collects all the appropriate information to determine whether the facility is in compliance with licensing laws.”

“If we identify deficiencies during the investigation, we issue a statement of deficiencies to the hospital. The next step is for the facility to provide a plan of correction for addressing those deficiencies,” the statement said.

In most cases, when deficiencies are identified, investigations result in a “collaborative process focused on ensuring the facility’s plan is sufficient to address deficiencies, comply with hospital licensing laws and protect patients’ safety and well being, as well as ensuring continued access to care,” the statement added.

In some instances, the health department can take enforcement actions that include denying, modifying or suspending facility licenses, the department indicated.

Wellfound’s licenses are currently active, according to a check by the Department of Health.

Records reveal a snapshot

While public records provide an incomplete snapshot of the two ongoing investigations dating back to August, they do shed light the scope of the investigation and its areas of focus, at least in the early stages.

A team of Department of Health investigators arrived at Wellfound for an on-site survey on Aug. 15, according to documents related to the investigation.

By then, the two cases — Carter Jr.’s suicide and the whistleblower complaint — had been combined into one investigative effort.

During the course of the day-long survey, the investigators planned to review medical records, hospital policies and procedures.

Investigators also interviewed staff, including care providers and executives. Time also was allotted for observing patient care, according to an itinerary included in the documents.

The investigators’ work included reviewing the adequacy of Wellfound’s suicide assessments and constant observation protocol, according to the documents.

Proper medical chart documentation and discharge planning were additional areas of focus for investigators.

According to handwritten interview notes, investigators questioned staff regarding training, organization and whether directives and the chain of command at the hospital were clear.

Plan for Correction

Available records suggest Wellfound has taken some corrective action in response to concerns raised by the state department of health.

On Aug. 16, records pertaining to the August complaints indicate Wellfound submitted what’s known as a “plan for correction.”

In it, the hospital promised to ensure that a “credentialed medical provider” would be “in the facility 24-hours per day to provide a medical screening exam for each patient presenting for care.”

The document is signed by current Wellfound acting CEO Matt Crockett, who arrived at the facility last year after previously holding a similar position at Smokey Point Behavioral Health in Marysville.

Based on records The News Tribune has obtained so far, it’s unclear what has transpired since. Wellfound submitted the document.

Broadly speaking, according to the state department of health, a plan for correction typically comes in response to deficiencies “identified ... during the investigation.”

Once a plan for correction is submitted, “the investigation team reviews (it) to verify it contains a description of the methods the hospital will use to correct each deficient practice to prevent recurrence and that the intent of the regulation is met,” according to a statement from the health department.

“The department may conduct another on-site visit to verify the hospital has implemented their plan of correction if the investigation resulted in egregious findings, such as an immediate risk to patient safety or if there are multiple non-compliance issues that place risk to patient safety,” the statement adds.

According to Wellfound, three Department of Health “facility reviews” have been conducted since August 2019.

“Often, these visits have findings that identify areas of opportunity to revise processes, implement facility improvements or make changes in protocols. We welcome these opportunities,” the hospital’s statement indicated.

“Wellfound submitted Plans of Correction that were immediately accepted by the DOH, changes were quickly implemented, and the DOH continued to monitor progress on the improvements.,” the statement continued. “No additional action has been required by the DOH.”

Citing the ongoing investigations, the Department of Health declined to confirm the hospital’s depiction.

Meanwhile, much more is known about the status of another recent plan of correction submitted by Wellfound.

Dating back to September, it’s publicly available online through the department of health’s website.

The September plan of correction, which also stems from an Aug. 15 Department of Health visit, “focuses on records and documentation issues,” according to MacCracken.

Those issues, McCracken said, are “an essential area for any health care facility ... and one that merited its own inspection.”

“The hospital responded quickly to resolve the deficiencies, so we were able to wrap up that part,” McCracken said.

“Other aspects are ongoing, and records of open investigations aren’t available online,” McCracken added.

Elopements and sentinel events

In a transcript of the Aug. 13 whistleblower complaint, which was included in public records obtained by The News Tribune, the anonymous employee claimed that Wellfound had experienced “one sentinel event and several elopements within the last two weeks.”

A sentinel event, according to the American Medical Association, is “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof, including any process variation for which a recurrence would carry a significant chance of a serious adverse outcome.”

In a hospital setting, according to the Joint Commission, an elopement is the unauthorized departure of a patient.

Both issues, along with patients who left the facility against medical advice — known as AMA in shorthand notes — became areas of interest for investigators.

According to investigation notes, at least three medical charts associated with patients who left Wellfound against medical advice were obtained.

Among other things, the notes suggest investigators reviewed potential AMA documentation issues at the hospital.

Meanwhile, in an Aug. 24 email between department of health investigators assigned to the case, one recent elopement is described at length.

According to the email, a male patient arrived with his father at Wellfound on Aug. 7, 2019. He was admitted to Wellfound’s crisis stabilization unit at 7:18 p.m., diagnosed with a severe episode of recurrent major depressive disorder, “without psychotic features ... and suicidal ideation.”.

Roughly three hours after being admitted, the patient “told staff he no longer wanted to stay,” according to the investigator’s notes.

The patient was subsequently informed that he was being held for evaluation by a designated crisis responder, or “DCR.”

According to the notes, a DCR was called at roughly 10 p.m., but by the following morning, the requested specialist had yet to arrive.

At 8:55 a.m., according to the document, the patient — who had become agitated during his stay and was placed on observation and administered the anti-anxiety drug Ativan — was able to slip out of the hospital through an emergency drop-off bay in the crisis stabilization unit.

“(Patient) bolted out CSU ambulance door while staff member using as an alternative entrance during front entrance construction,” the investigator’s email concludes, drawing from the hospital’s incident report.

Moving forward

At the time of Wellfound’s long-awaited Joint Commission accreditation announcement late last year, CHI Franciscan CEO Ketul Patel predicted the hospital would be “fully operational” by the end of 2020.

Nearly two months later, the plan is moving forward, according to the hospital.

In October, following the hospital’s self-imposed temporary hold on admissions, the facility reopened with eight inpatient beds in operation.

According to the hospital’s statement, Wellfound now plans to have “36 beds open by the end of February,” describing the ongoing ramp up as part of “a purposeful sequencing.”

Wellfound still anticipates all of its 120 beds being available by the end of the year, the hospital told The News Tribune.

Asked about the ongoing investigations, Wellfound noted that the new facility is currently open and “meets all requirements set by the DOH and is accredited by the Joint Commission.”

“Wellfound is 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,” according to the hospital’s statement. “Key to our care and treatment is our continuous effort to refine processes and procedures and make system refinements.”

“As is typical with behavioral health hospitals, we are regularly working with our physicians, clinicians and all staff to ensure they are trained in the best care methods for our patients,” the hospital said.

Matt Driscoll is a reporter and The News Tribune’s metro news columnist. A McClatchy President’s Award winner, Driscoll lives in Central Tacoma with his wife and three children. He’s passionate about the City of Destiny and strives to tell stories that might otherwise go untold.
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