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CAMBRIDGE HEALTH ALLIANCE 1493 CAMBRIDGE STREET CAMBRIDGE, MA 02138 June 27, 2019
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on records reviewed and interviews the Hospital failed for three patients (Patient #6, #7 & #9) of five sampled patients in a total sample of ten patients to ensure that Quality Improvement and Performance Improvement (QAPI) activities identified opportunities for improvement following Patient #6's adverse patient event regarding providing obstetrical hemorrhage risk screening for all obstetrical patients.

Findings included:

The Patient Safety and Performance Improvement Plan, dated 2019-2013, indicated that the Hospital used performance improvement methods (activities) to improve patient care.

The Hospital policy titled Obstetrical Hemorrhage, dated 2/20/19, indicated maternal newborn service providers (Physicians and Certified Nurse Midwives) and staff (Nursing) were responsible to provide an obstetrical hemorrhage risk screening for all obstetrical patients.

Medical review of five patients, selected from the Obstetric Hemorrhage Log dated 1/1/19-6/26/19, indicated three patients (Patients #6, #7 & #9) with either incomplete or lacking an obstetrical hemorrhage risk screening.

Regarding Patient #6:

The History and Physical, dated 4/3/19, indicated no documentation of obstetrical hemorrhage risk screening as required by the Obstetrical Hemorrhage Policy for all obstetrical patients.

The Admission Postpartum Hemorrhage Risk, dated at 4: 17 P.M. on 6/26/19, indicated no documentation of a nursing obstetrical hemorrhage risk screening as required by the Obstetrical Hemorrhage Policy for all obstetrical patients.

Regarding Patient #7:

The History and Physical, dated 5/12/19, indicated no documentation of obstetrical hemorrhage risk screening as required by the Obstetrical Hemorrhage Policy for all obstetrical patients.

The Admission Postpartum Hemorrhage Risk, dated at 5:25 P.M. on 6/6/19, indicated a nurse did not perform a nursing obstetrical hemorrhage risk screening.

Regarding Patient #9:

The Admission Postpartum Hemorrhage Risk, dated at 2:35 A.M. on 3/26/19, indicated the nursing obstetrical hemorrhage risk screening was incomplete.

The Surveyor interviewed the Maternal Newborn Director during the medical record review at 4:00 P.M. on 6/26/19, who navigated the obstetric medical records. The Maternal Newborn Director said that there was no documentation (Provider documentation in the History and Physicals) of a hemorrhage risk evaluation (obstetrical hemorrhage risk screening) for of Patients #6 & #7. The Maternal Newborn Director said the nursing staff missed the documentation of Patient #6's initial post-partum hemorrhage evaluation (obstetrical hemorrhage risk screening). The Maternal Newborn Director said the nursing documentation of Patients #7 & #9's post-partum hemorrhage evaluation was incomplete.