The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CAMBRIDGE HEALTH ALLIANCE 1493 CAMBRIDGE STREET CAMBRIDGE, MA 02138 Sept. 3, 2013
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and interviews, the Hospital failed to notify Patient #1's (Pt. #1) family of his/her admission in a timely manner for one of eleven applicable patients.

The Hospital Emergency Department (ED) Provider Notes, dated 6/1/13 at 4:40 P.M., indicated that Pt. #1 presented to the ED by ambulance for altered mental status after being found unconscious in a car. The ED Provider Notes indicated that Pt. #1 was unresponsive with a Glascow Coma Scale (GCS-a measure of the level of consciousness of a patient which is scored between 3 and 15 with 3 being the worst, and 15 the best) of 3, agonal respirations (abnormal pattern of breathing), heart rate of 169 (normal 60-100) and a temperature of 104.2 F (normal 97.8-99 F). The ED Provider Notes indicated that Pt. #1 was intubated (breathing tube placed into the windpipe to assist with breathing) and admitted to the Intensive Care Unit (ICU). The ED Provider Note indicated that Pt. #1 had no past medical history on file at the Hospital.

The Surveyor interviewed the ED Registered Nurse (ED RN) by telephone, with the Risk Manager and ED Nurse Manager in attendance, on 9/5/13 at 11:45 P.M. The ED RN said that she was Pt. #1's caregiver on 6/1/13 while Pt. #1 was in the ED. The ED RN said that she checked Pt. #1's wallet for his/her license to in order to obtain his/her name and address. The ED RN said that she did not look for any relatives telephone numbers in his/her wallet at that time. The Risk Manager said that the Hospital does not have a formal policy or procedure in place which outlines how to notify next of kin in a situation like this.

The Nursing Progress Notes, dated 6/1/13 at 10:15 P.M., indicated that Pt. #1 was admitted to the ICU at 7:10 P.M.

The Surveyor interviewed the ICU Registered Nurse (ICU RN) by telephone, with the Risk Manager and the ICU Nurse Manager in attendance, on 9/9/13 at 10:26 A.M. The ICU RN said that she was Pt. #1's caregiver on the 7:00 P.M. to 7:00 A.M. shift on 6/1/13-6/2/13. The ICU RN said that she did not attempt to notify Pt. #1's family and thought that one of the physicians might have tried.

A Physician Progress Note, dated 6/2/13 at 10:33 A.M., indicated that the Police were notified in an attempt to locate Pt. #1's relatives.

The Surveyor called the Police, in the town where Pt. #1 resided, on 9/12/13 at 12:45 P.M.. The Police verified that they received a call from the hospital on [DATE] at 7:50 A.M. and responded to Pt. #1's address in an attempt to locate a relative of Pt. #1.