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.

UMASS MEMORIAL HEALTHCARE-MARLBOROUGH HOSPITAL 157 UNION STREET MARLBOROUGH, MA 01752 May 14, 2015
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
The Hospital failed to consistently provide adequate personal protective equipment (PPE), to prevent potential aerosolization of pathogens from a flush rim sink and to design an infection control compliant central decontamination area.

1) The CDC Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, indicated personal protective equipment was a variety of barriers and respirators used alone or in combination to protect mucous membranes, airways, skin, and clothing from contact with infectious agents.
Observation in the Endoscopy reprocessing room at 10:30 A.M. on 5/14/15, indicated barrier protection gowns (KC200) were provided. The Endoscopy Technologist said he routinely donned this protective gown to reprocess endoscopes. According to the manufactures guidelines, this protection gown was designed when risk of exposure to fluid is between low and moderate, instead of providing an impermeable gown as required for this task.

2) The Surveyor observed a clinical service sink in the PACU at 7:25 A.M. on 5/ 14/15. The clinical service sink was not in an enclosed area that would contain aerosolized matter when the clinical service sink was flushed. The area was in close proximity (approximately five feet) from the potable ice machine.

3) The Surveyor observed the central decontamination room at 8:15 A.M. on 5/14/15. The decontamination room was located directly adjacent to the Operating Room's semi-restricted corridor. A semi-restricted area comprises the peripheral support areas surrounding the restricted area of a surgical suite. These support areas include facilities such as storage areas for clean and sterile supplies, sterile processing rooms and personnel in the semi-restricted area wear surgical attire.
The Certified Sterile Technician was interviewed at 9:30 A.M. on 5/14/15. The Certified Sterile Technician said the decontamination room was used to reprocess all the Hospital's instrumentation and supplies for sterilization. The Certified Sterile Technician said the decontamination room contained the only washer disinfectant machine in the Hospital. The Certified Sterile Technician said instruments used outside of the Operating Room that required reprocessing were brought to a central area through the semi-restricted corridor to the decontamination area, within the Operating Room. The Certified Sterile Technician said the decontamination room was originally located on another floor of the Hospital but was relocated some years prior. The Certified Sterile Technician said the autoclave and gas sterilizing equipment remained in the previous location and instruments were wrapped in a clean room and then transported to be sterilized.

However, because of the design and flow of this central decontamination area the potential for cross contamination during transport and/or reprocessing of soiled equipment does not meet infection control standards.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
Based on record review and interview, the hospital failed to provide post care information for 4 of 4 applicable discharged patients (#2, #3, #4 and #5) in a total sample of 5, with completed reconciled medication discharge instructions that identified changes in medications made during the patient's hospitalization and identified the last dose of medications was given and/or the next dose was due. Findings include;

1. Review of the discharge/transfer instructions for Discharge Record Review Patient #2, indicated, the patient was discharge with home care services on 4/16/15, back to an assisted living facility. Record review indicated the patient had short term memory problems and had cognitive limitations.

Review of the discharge medication instructions indicated that the medications were all marked as "no changes" but except for two which were new medications. However, the column for next dose due was left blank for all medications.

One of the new medications was ordered to be taken every eight hours (Flagyl 500 milligrams, an antibiotic for bowel infection) and the other, sodium bicarbonate 325 mg, was ordered three times a day. The medication discharge instructions did not specify when (at what times) the patient should take these medications. All the other medications were daily.

2. Review of the discharge/transfer instructions for Discharge Record Review Patient #3, indicated, the patient was discharged to a skilled nursing facility (SNF) on 4/19/15 status post a right total hip replacement.

Review of the discharge medication instructions indicated that the medications were not marked as "no changes" and there was no indication of when the next dose was due for any of the 9 medications the patient was prescribed. The patient was newly prescribed Coumadin, a blood thinner. There was no indication on the medication discharge instructions when the last dose of coumadin was given or the next dose due.

3. Review of the discharge/transfer instructions for Discharge Record Review Patient #4, indicated, the patient was discharged to a skilled nursing facility (SNF) on 4/6/15 status post treatment for exacerbation of chronic lung disease and congestive heart failure.

Review of the discharge medication instructions indicated that the medications were not marked as "no changes" and there was no indication of when the next dose was due for any of the 11 medications the patient was prescribed, including sliding scale insulin coverage. Stopped medication were indicated at the end of the medication instructions, however Colchicine and Eloquis appeared on both lists.

4. Review of the discharge/transfer instructions for Discharge Record Review Patient #5, indicated, the patient was discharged to a skilled nursing facility (SNF) on 4/13/15 status post treatment for acute bronchitis.

Review of the discharge medication instructions indicated that the medications were not marked as "no changes" and there was no indication of when the next dose was due for any of the 18 medications the patient was prescribed. Stopped medication were indicated at the end of the medication instructions.

5. During an interview on 5/14/15 at approximately 12:00 P.M., the Interim Director of Case Management said that the discharge medication instructions page of the referral were a joint effort between nursing and case management. The Director said the discharge medication referral instructions were not completed .
VIOLATION: REASSESSMENT OF DISCHARGE PLANNING PROCESS Tag No: A0843
Based on review of Quality Assurance/Performance Improvement minutes and date, review of Utilization Review minutes, review of policies and procedures, record review, and interviews, the Hospital did not have a process in place to identify, review, analyze and implement correct actions for discharge planning related to 30 days readmissions and failed to assess the reasons for less than 30 day readmission for four of four discharge patients (#2, #3, #4 and #5), in a total sample of 5. Findings include:

1. Review of the Case Management (CM) policy and procedure, titled "Care Coordination, Discharge planning and Referral Process, revised 4/13/15, indicated case manager will document in the medical record, if the patient is readmitted within thirty days, any factors that may have contributed to the readmission.

2. During an interview on 5/14/15 at 10:00 A.M., the Interim Case Manager for Discharge Planning said part of the case management admission assessment is a readmission assessment that tries to determine why the patient has been readmitted .

3. Review of the CM readmission assessment indicated a question for why the patient and/or family thought they returned to the Hospital and what did not work at home, i.e., trouble with medications.

4. Review of the readmission assessment, dated 4/16/15, for Discharge Patient #2 indicated it was blank except for a diagnosis section that indicated the patient had a diagnosis of bowel infection. Record review indicated the patient had been discharged in the previous 30 days with a diagnosis of sinoatrial node dysfunction. The Director said there were no other assessments for readmission in the other records for Patients #3, #4 and #5 who also had 30 day readmissions.

5. Review of the past two months discharges indicated the following:
a. In March 2015, there were 71 admissions of which 12 were readmissions.
b. In April 2015, there were 32 admission of which 13 were readmissions.

6. Review of the QAPI data indicated that the Hospital was tracking the number of readmissions monthly for categories of Congestive heart failure, Anterior wall infarct (AMI), COPD, and total number all readmissions but was not analyzing the data or trending it.

7. During an interview on 5/14/15 at 10:00 A.M., the Interim Case Manager for Discharge Planning said that the Hospital does track the number of 30 day readmissions to the Hospital but does not do root cause analysis for why patients are readmitted and does not have a performance improvement plan in place to reduce the number of 30 day readmissions.