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 July 19, 2017
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observation, record review and interview for 1 of 11 sampled patients (Patient #11), the Hospital failed to ensure its Emergency Department (ED) staff continuously observed Patient #11 on 7/18/17, as was required by Hospital policy due to his/her risk for self harm and elopement.

Findings include:

The Hospital policy for Patient Safety Watch, dated 4/1/16, indicated that the Public Safety Officer/Security Officer, per Emergency Department Physician's order, is to provide line of sight observation of a patient who is determined to be at risk for one or more of the following indicators: elopement risk, imminent risk of self injury or actively suicidal with or without evidence of an active plan and/or verbalized intent or engagement in deliberate harm to self. The Patient Safety Watch Policy indicated that, if the ED staff allows the patient to ambulate to the bathroom, the patient will be escorted to the bathroom by an ED staff member. A Public Safety Officer/Security Officer will escort the patient as well to ensure the safety of the escorting staff member and others in the area.

Patient #11's physician orders, dated 7/18/17 at 12:12 P.M., indicated continuous safety watch due to self-harm and to prevent elopement.

Patient #11's Patient Safety Watch Flow Sheet, dated 7/18/17, indicated he/she was supervised by Safety Officers beginning at approximately 8:00 A.M. and through 2:00 P.M.

The Surveyor observed Patient #11 on 7/18/17 at 2:00 P.M. The surveyor observed Patient #11 open a closed bathroom door located in the hallway of the behavioral health wing of the ED. Patient #11 exited the bathroom and walked, by himself/herself, through the hallway and entered room #18 which was approximately 15 feet away. The Surveyor observed a Safety Officer standing approximately 20 feet away from the bathroom door in front of another patient's room. There were no other staff outside the bathroom door or accompanying Patient #11 in the hallway during this time.

The Surveyor interviewed the ED Nurse Educator on 7/18/17 at 2:05 P.M. The ED Nurse Educator said it was Hospital policy for a Safety Officer to accompany a patient under continuous observation status to and from the bathroom. The ED Nurse Educator said it was Hospital policy that, during bathroom use, line-of-sight observation is not to be broken. The ED Nurse Educator said staff are required to keep the bathroom door sufficiently open to enable visual observation of the patient at all times.

The Surveyor interviewed the ED Nurse on 7/18/17 at 8:50 A.M. The ED Nurse said that, when a patient has a physician's order for continuous observation, either a Safety Officer or nurse is required to provide continuous line of sight observation of the patient. The ED Nurse said that, if the patient needs to use the bathroom, a Safety Officer must accompany the patient to the bathroom and keep the door open to maintain continuous observation.

The Surveyor interviewed the Public Safety Officer on 7/19/17 at 9:08 A.M. The Public Safety Officer said that patients on continuous observation status were allowed to use the bathroom with the door completely shut, unless the police were involved in the patient's supervision and the police chose to require to have the door open.

The Surveyor interviewed the ED Behavioral Health Nurse on 7/19/17 at 9:15 A.M. The ED Behavioral Health Nurse said a patient with a physician's order for continuous observation required either a Safety Officer or nurse to maintain continuous observation of the patient while he/she is in the ED to ensure safety. The ED Behavioral Health Nurse said that if a patient with this status needs to use the bathroom, he/she is allowed to close the door for privacy. The ED Behavioral Health Nurse said that patient's who are actively suicidal do not require the bathroom door to remain open because they are wearing a hospital gown and are not carrying contraband.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on records review and interview, the Hospital failed to consistently ensure that first aide techniques were included in the restraint education for the contracted security staff who might provide watch services to a restrained patient on the Everett Campus.
Findings included:

Review of Contract Security Staff #1's education and training file indicated there was no documentation that she was trained or certified in first aid.

The Surveyor interviewed the Chief of Public Safety and Security at 11:00 A.M. 7/19/17. The Chief of Public Safety and Security said that the contracted security staff might be detailed to observe a patient in restraints. The Chief of Public Safety and Security said the licensed staff completed the periodic assessment for the restrained patient but that the contract security staff were able to provide the one-to-one observation of the restrained patient. The Chief of Public Safety and Security said the contracted security staff were required to be CPR certified but were not required to have first aide training.
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observations, record reviews, and interviews, it was determined the Hospital failed to protect and promote patient's rights.

Findings include:

1. The Hospital failed to provide care in a safe setting.

See A-0144.

2. The Hospital failed to ensure staff were trained in first aid techniques and certification in the use of cardiopulmonary resuscitation, including required periodic recertification.

See A-0206.