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.

NORTH SHORE MEDICAL CENTER - 81 HIGHLAND AVENUE SALEM, MA 01970 June 10, 2019
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
A-0144

Based on observations and interview the Hospital failed to follow their policy and procedure to maintain a safe environment on the Adult Behavioral Health Unit.

The Surveyor toured the secured Adult Behavioral Health Unit (7 E) and interviewed the Nurse Manager of the Unit at 3:00 P.M. on 6/6/19. The Surveyor observed the housekeeping cart in the corridor of 7 E with a number of broom and mop handles easily accessible which could be used by a patient to harm either another patient or staff. The Nurse Manager said that the policy on their secured unit was to have the cart attended to at all times. There was no housekeeping attendant in sight. The Surveyor opened the side compartment of the cart and there were multiple plastic bags which could be used as a means of self-harm.

The Surveyor interviewed the housekeeper at 3:10 P.M. in the alcove outside of 7 E. Housekeeper #1 said she had been with the Hospital about 6 months but that 7 E was not her usual assignment. Housekeeper #1 said that she was a "float" and worked on a number of different units. Housekeeper #1 said she had been trained to work on 7 E.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0206
Based on observations, records reviewed and interview the Hospital failed to ensure that First Aid and Cardiopulmonary resuscitation (CPR) was provided to their vendor personnel who were involved in restraint situations.

The Surveyor observed vendor staff on the secured Adult Behavioral Health Unit (7 E) and interviewed the Risk Manager at 3:10 P.M. on 6/6/19. The Risk Manager said that the Hospital used this vendor as supplemental staff on the secured Adult Behavioral Health Unit (7 E) and in the emergency room . The Risk Manager said that the vendor service might respond to a restraint situation but would not apply a restraint themselves but might assist other staff members in a restraint situation. The Risk Manager said the vendor staff person might hold a limb (a form of restraint) under the direction of the Hospital staff.

The Surveyor reviewed the vendor education binder at 7:30 A.M. on 6/10/19. The vendor binder contained numerous educational profiles for the staff that was sent to the Hospital to work. Of the first twelve profiles reviewed ten of the twelve did not have the required First Aid or CPR certification to participate in restraint application.
VIOLATION: PATIENT RIGHTS: ADVANCED DIRECTIVES Tag No: A0132
Based on records reviewed and interview, the Hospital failed to follow their Informed Consent Policy for one (Patient #2) patient of ten patients sampled who required informed consent for a surgical procedure.

The Hospital Policy titled Informed Consent, dated 7/2016, indicated the consent form must be signed by the patient except when a.) the patient is a minor, b.) the patient is mentally incompetent with written documentation of such decision, c.) the patient is physically incapacitated or d.) the patient is so distracted that he cannot understand (i.e. sedated or anxious).

The Surveyor reviewed the informed consent for Patient #2 who required extensive abdominal surgery. Patient #2's surgery was not an emergency and Patient #2's medical record indicated that the surgeon provided Patient #2's son, in the presence of Patient #2, with the details of the planned surgical procedure. The informed consent was subsequently signed by the son. Patient #2 was non-English speaking and there was no evidence that an interpreter was provided. Also, Patient #2 had not been deemed mentally incompetent nor had Patient #2's health care proxy been activated.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on observations and interview the Hospital failed to provide privacy for one (Non-Sampled Patient #1) of three patients on telemetry (a continuous visual monitor of the heart rhythm).

The Surveyor viewed the telemetry screen on Phippen 7 at 9:15 A.M. on 6/10/19 and interviewed the Nurse Director of the Unit. The Surveyor observed the telemetry screen where three patients were being monitored. The telemetry screen was located in a public walkway that was visible to anyone walking by the screen. One of the three patients had their full first and last name posted.
The Nurse Director said the policy of the Unit was to use two patient identifiers but to protect the patient's identity.