Matt Driscoll

‘High risk of serious harm.’ Multiple violations found at Tacoma psychiatric hospital last year

Last year, investigators with the state Department of Health identified roughly 70 pages of deficiencies at Wellfound Behavioral Health Hospital in Tacoma, many of them potentially serious.

In one extreme example, investigators determined the new psychiatric hospital’s failure to provide medical screenings to patients seeking care at the facility’s crisis stabilization unit resulted in “a high risk of serious harm, injury, and death,” according to documents recently obtained by The News Tribune.

Numerous other issues at the hospital potentially put “patients at risk for harm,” Department of Health investigators concluded.

The documents, which are part of a larger, ongoing public records request submitted by The News Tribune, are tied to two ongoing Department of Health investigations into Wellfound. The paper reported on the existence of the investigations last week, relying on a previous installment of records

The latest batch of records, which arrived more recently, shed significant light on both investigations while also providing the clearest evidence to date of the extensive violations investigators formally identified after their 2019 visits to the hospital.

The documents also illuminate the steps Wellfound has promised to take to address them in the months that followed.

For Wellfound, changes at the hospital in recent months have been far reaching, records reveal, touching everything from policy, training and staffing to upper management and the facility itself.

One important shift includes Wellfound’s decision to “refocus” its crisis stabilization unit, a plan the hospital referenced throughout the lengthy Plan of Correction it submitted to the state in response to the identified deficiencies.

In September, according to the documents, Wellfound replaced the unit with what the hospital described as an “intake and assessment area.”

While the crisis stabilization unit was often described as a key feature of the $41 million CHI Franciscan and MultiCare venture — which ultimately benefited from millions in public contributions from Tacoma, Pierce County and the state — Wellfound said the change will have little impact on patients or the hospital’s ability to provide care.

According to a statement provided by the hospital, “refocusing” the crisis stabilization unit will “not restrict the types of patients Wellfound admits or the number of beds Wellfound intends to have available to patients once the hospital is fully operational.”

As it has in the past, Wellfound described the long list of deficiencies identified by the Department of Health as “typical in scope and number for a new behavioral health hospital.”

Allegations substantiated

The Department of Health’s first open investigation into Wellfound dates back to Aug 9, the day The News Tribune first published its story on suicide death of 29-year-old Kevan Carter Jr., a Wilson High School grad and hip-hop artist.

As the paper reported, Carter Jr. had a history of mental illness and sought care at Wellfound twice in a 24-hour period in late July. Hospital staff sent Carter Jr. home each time, determining he didn’t meet the criteria for admission.

A few hours after being discharged for the final time, Carter took his life by stepping in front of a moving train near his childhood home of Titlow Beach.

Later in August, the Department of Health opened a second investigation into Wellfound, this one in response to a whistleblower complaint lodged by a hospital employee.

That complaint alleged Wellfound was accepting patients to its crisis stabilization unit without the proper state license.

Investigators substantiated the allegation during the course of their work, according to documents, determining the hospital was “providing patient care in the outpatient unit (CSU) without appropriate licensure.”

Additionally, investigators determined the hospital also failed to “provide a safe and secure environment” for patients and engaged in “unsafe infection control practices.”

All told, according to available records, the Department of Health investigations have resulted in at least eight broad citations against Wellfound.

The eight citations are violations of state hospital law and regulations related to state licensing requirements, according to Department of Health spokesperson Gordon MacCracken and an investigative summary included in the documents.

According to the state agency, both cases are open, limiting what agency officials can say. MacCracken declined to respond to questions about whether additional citations have been issued or if all of Wellfound’s corrective actions have been accepted.

According to Wellfound, the hospital has “welcomed” the investigations, and complied with all Department of Health findings to date.

“All changes have been implemented and no additional action has been required by the DOH,” the statement added, noting that deficiencies identified in August were “addressed more than six months ago.”

The Department of Health was able to confirm that the hospital’s licenses are currently active and, to date, no enforcement actions have been taken.

Previously, the agency has described the investigation process as “collaborative.”

Multiple failures

In total, investigators identified more than 30 individual deficiencies at the hospital during the course of their investigations, according to a statement of deficiencies issued to the hospital.

The investigators’ findings, which largely date back to August, range in severity.

Some are seemingly minor, like a lack of shelving in housekeeping closets.

Other deficiencies appear far more significant.

For instance, on Aug. 16 investigators flagged Wellfound’s failure to ensure that a credentialed provider was at the hospital 24-hours a day to provide medical screening exams as an “immediate risk to patient safety.”

On Aug. 18, they returned to verify the problem had been addressed, the records show.

Documents indicate the hospital’s efforts to address numerous other deficiencies continued at least into October .

The identified deficiencies include inadequate unit-specific policies, insufficient medical documentation, gaps in training, and flaws with the hospital’s risk observation and precaution protocol. Many relate to patient care and services.

Additionally, investigators concluded that Wellfound’s governing body — which they noted is ultimately “responsible for the delivery of patient care within the facility” — failed “to monitor and evaluate” the quality of the hospital’s “patient care services.”

Specifically, investigators said the hospital’s top officials failed to “to develop and implement a coordinated, integrated hospital-wide quality and performance improvement program.”

As-needed medication

Deficiencies related to the hospital’s administration of “as-needed” medication also were identified by Department of Health investigators, according to records.

Specifically, the state agency identified multiple instances where Wellfound staff “failed to ensure staff members completed and documented reassessments after each ‘as-needed’ medication intervention,” the documents show.

In three cases, investigators found no evidence the hospital had reassessed patients after administering Lorazepam, which is often prescribed in behavioral health settings to treat anxiety.

In another instance, investigators determined that a patient had waited 4 hours, 19 minutes to receive the medications prescribed by a provider.

Legionella in the water

As part of the Department of Health’s investigations, agency investigators reviewed Wellfound’s infection control and water-management program.

Investigators concluded the hospital failed to implement processes involved in its infection control and prevention plan, including issues related to infection surveillance and analysis.

According to records, staff interviewed at Wellfound told investigators there “had been gaps in the infection prevention meetings and monitoring process and that the committee had not adequately discussed infection control related issues.”

At the time, the state’s investigations also found that Wellfound’s infection preventionist “lacked documented qualifications to oversee the program,” according to documents .

The potential spread of waterborne infections was also flagged by investigators, documents show.

Concerns included multiple positive tests for Legionella in Wellfound sinks and one shower, the records indicate.

According to those records, at least eight staff members were exposed to the contagious bacteria, which is associated with Legionnaires’ disease, a severe form of pneumonia, according to the Mayo Clinic.

None of the employees tested positive for infection, investigators noted.

Elopements and AMA

In addition to licensing concerns, the Aug. 13 whistleblower complaint lodged by an employee at Wellfound alleged the hospital had experienced “several” recent elopements.

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

During the course of their investigation, Department of Health officials reviewed at least two elopements at Wellfound, both occurring through the hospital’s ambulance bay doors.

Based on their August on-site survey, investigators found the doors contributed to the problem.

Multiple Wellfound employees confirmed issues related to the doors, according to documents related to the investigations, with one telling investigators, “There had been multiple issues with the door and multiple occurrences of patient elopement, including elopements of involuntarily held patients.”

Separate from patient elopements, Department of Health investigators focused on Wellfound patients who decided to leave the facility with permission from their provider but against medical advice — or AMA for short.

State hospital regulation related to AMA patients requires proper documentation, including a patient signature.

At Wellfound, according to documents, Department of Health investigators “identified five instances where patients left AMA and found no records indicating proper documentation has been completed.”

In one instance, records show, on Aug. 16 investigators observed a patient leave the facility against medical advice.

“The investigator observed that the hospital staff was unaware and unable to find the required AMA form for the patient to sign,” according to documents.

“Immediately following the observation, Investigator #3 interviewed the charge nurse ... who stated that she and the other nursing staff had not been trained on that hospital policy and procedure,” investigators noted.

Third investigation

During the course of reporting, The News Tribune learned of a third open investigation into Wellfound launched by the Department of Health in November.

Documents recently obtained by the paper indicate the investigation came in response to an allegation that Wellfound improperly detained a patient who had attempted to leave the hospital.

In response, investigators again visited Wellfound in December, with investigators ultimately identifying no deficiencies, records show.

As part of the investigation, the patient and their family were interviewed, with one telling investigators staff at the hospital were “very, very nice and compassionate.”

Crisis Stabilization Unit

During the course of their investigation, Department of Health investigators identified multiple deficiencies related to Wellfound’s crisis stabilization unit and the policies pertaining to it.

Last year, writing in response to the death of Carter Jr., Wellfound acting CEO Matt Crockett sent a memo to employees indicating the hospital was “assessing work flows and many procedures in the (crisis stabilization unit) and inpatient units.”

“We are looking for opportunities to ensure our work is safe and comprehensive,” Crockett’s memo continued.

The following month, the hospital decided to convert the crisis stabilization unit, according to documents obtained by The News Tribune.

In its place, according to documents, Wellfound will operate what it describes as an “Intake and Assessment Department.”

According to a statement from the hospital, the crisis stabilization unit “has been refocused as part of the intake and assessment area.”

The intake and assessment process to be conducted in the new department, according to the hospital, will include a medical assessment conducted by a behavioral health specialist.

From there, the hospital will determine the level of care a patient requires, develop of a treatment plan if admitted, and initiate an assessment by a designated crisis responder, or DCR, if necessary.

Course of correction

In response to the lengthy list of deficiencies Department of Health officials provided to Wellfound, the psychiatric hospital submitted a Plan of Correction to the agency.

The document represents the hospital’s specific plan for fixing the deficiencies, as required by the state.

Over the course of roughly 20 pages, Wellfound’s plan outlines steps the hospital planned to take to address issues identified by investigators.

Some, like the hospital’s promise to have a credentialed medical provider available for medical screening exams 24 hours a day, were corrected in August, according to the document.

Other issues, like deficiencies in Wellfound’s patient care policies, governing body oversight, medication administration and AMA policies were estimated to be corrected by October, the document show.

Department of Health public disclosure officials have indicated that more documents pertaining to The News Tribune’s records request are forthcoming.

It’s unclear whether Wellfound has sufficiently responded to all deficiencies identified during the course of the two ongoing investigations.


May 2019: Wellfound opens for care on a limited basis.

June 2019: Wellfound decides to “pause” the hospital’s effort to achieve accreditation through the nonprofit Joint Commission, surprising and disappointing a number of local officials who championed the CHI Franciscan and MultiCare effort. The accreditation is optional but important. It’s required for the hospital to bill many insurers, including Medicaid and Medicare.

June 2019: Original Wellfound CEO Maureen Womack leaves the hospital. No reason is given for Womack’s departure. Matt Crockett, formerly of Smokey Point Behavioral Hospital, is tapped as an interim replacement. Crockett continues to serve as Wellfound CEO.

July 2019: Kevan Carter Jr. steps in front of a train and takes his own life after being sent home from Wellfound twice in a 24-hour period.

Aug 2019: Writing in response to Carter’s suicide, and The News Tribune’s coverage of it, Wellfound acting CEO sent a memo to employees indicating the hospital was “assessing work flows and many procedures in the (crisis stabilization unit) and inpatient units.”

The hospital subsequently places a temporary hold on admissions to its crisis stabilization unit.

At the time, Wellfound’s decision left just eight of the hospital’s 120 beds open to patients.

Aug. 2019: The Department of Health initiates two investigations into Wellfound. The first was spurred by Carter’s suicide. The second came in response to a whistleblower complaint. Investigators conduct onsite surveys between Aug. 13 and Aug. 27.

Sept. 2019: The News Tribune reports that all of Wellfound’s beds are empty while the hospital prepares for Joint Commission surveyors to revisit the hospital.

Sept. 2019: Department of Health investigators present Wellfound with a “Statement of Deficiencies” related to both investigations, detailing more than 30 individual and wide-ranging findings.

Wellfound responds by submitting a lengthy “Plan of Correction” to the state, detailing changes the hospital will make in response to the deficiencies. The documents indicate most are to be completed by October.

Sept. 2019: Wellfound “refocuses” its crisis stabilization unit, converting it to what the hospital now describes as an “Intake and Assessment Department.“

Department of Health Investigators had identified a number of deficiencies related to policy and patient care at Wellfound’s crisis stabilization.

Oct. 2019: Wellfound reopens with eight inpatient beds in operation.

Nov. 2019: The Department of Health initiates a third investigation into Wellfound. The hospital is subsequently cleared of wrongdoing.

Dec. 2019: Wellfound announces it has obtained Joint Commission accreditation, indicating the hospital plans to be “fully operational” by the end of 2020.

The hospital reiterated that plan as recently as last week.

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.