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.

EMERSON HOSPITAL - 133 OLD ROAD TO 9 ACRE CORNER W CONCORD, MA 01742 Sept. 26, 2012
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on review of the Hospital's Internal Investigation and Corrective Action Plan related to a patient injury that occurred during a Code Gray (a team response for management of aggressive behavior) on 8/17/12, it was determined that the Hospital had not completely implemented the Corrective Action Plan.

Findings include:

The Hospital Internal Investigation related to the patient injury that occurred during the 8/17/12 Code Gray indicated that Patient #1 was wielding a metal butter knife and threatening to stab staff. Staff were attempting to de-escalate Patient #1's behavior when he/she suddenly lunged at Security Guard #1. Security Guard #1 took hold of Patient #1's hand and wrist and removed the knife. Security Guard #1 heard a popping sound during the process of removing the knife. A follow-up x-ray revealed a fractured wrist bone. The Hospital Internal Investigation identified issues related to the organization and management of the Code Gray and a Corrective Action Plan was developed.

The Corrective Action Plan called for: a.) revision of the Code Gray policy/procedure to clearly identify team member roles and responsibilities, b.) adding a behavioral health clinician to the Code Gray team, c.) staff education regarding the revised Code Gray policy/procedure and d.) Crisis Prevention Intervention training for Nursing Supervisors.

As of 9/26/12, the Corrective Action Plan was not implemented.