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.

ST ELIZABETH'S MEDICAL CENTER 736 CAMBRIDGE STREET BRIGHTON, MA 02135 June 6, 2019
VIOLATION: PATIENT RIGHTS Tag No: A0115
The Hospital was out of compliance with the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to communicate environmental and behavioral safety risks to the attending psychiatrist for one (Patient #1) patient out of a total of ten patients sampled.

Refer to TAG: A-0144.
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the Hospital failed to communicate environmental and behavioral safety risks to the attending psychiatrist for one (Patient #1) patient out of a total of ten patients sampled.

Findings include:

The Hospital reported that, on 5/29/19, Patient #1 was found outside the Hospital unresponsive from an apparent fall/jump from his/her room located on the 7th floor of the Hospital. Patient #1 was pronounced dead on the scene by responding Emergency Medical Services (EMS).

Patient #1 was admitted on [DATE] for bilateral calcaneus (heel bone) fractures sustained after he/she jumped from a window at home. Patient #1 believed he/she was the target of an assassination attempt and was experiencing paranoid thoughts at the time he/she was injured. Patient #1 was brought to a tertiary care facility and was placed on a Section-12 for safety. Patient #1 was then transferred to St. Elizabeth's Medical Center for surgical repair of his/her heels and for psychiatric evaluation.

Hospital Records indicate that, on 5/3/19 and on 5/10/19, Patient #1's right and left heels were surgically repaired. Patient #1 was placed on a 1:1 for safety while he/she was recovering on the medical surgical unit on the 7th floor.

The Hospital document titled Psych Progress Note, signed on 5/15/19 at 4:24 P.M., indicated that Patient #1 was assessed by Psychiatry Resident #1 and Patient #1 was no longer exhibiting impulsive behavior and was found to no longer meet the criteria for a Section-12 inpatient psychiatric patient. Psychiatric Resident #1 discussed the plan of care with the Psychiatric Attending and Patient #1's 1:1 observation was discontinued and he/she would no longer require an inpatient psychiatric bed.

The Hospital document titled Limited Brief Communication, signed on 5/15/19 at 10:42 P.M., indicated that Resident #2 spoke with Patient #1's family (mother, sister, and brother-in-law) who had objections to his/her clearance from psychiatry. The family stated that Patient #1 was rational when speaking to the medical team but continued to be paranoid and was experiencing bizarre thoughts with them. The family was concerned that Patient #1 needed continued psychiatric care. The document indicated that the psychiatric consult team would be informed of the family's objections. There was no evidence that the attending psychiatrist was notified about the family's concerns.

Review of the Hospitalist's Progress Note, dated 5/16/19 at 5:58 P.M., indicated that nursing called the Hospitalist to report that Patient #1 was found in his room standing on a chair and banging on the window. Patient #1 said that his/her roommate was making noises and Patient #1 "could not handle it any longer". Patient #1's roommate was moved and Patient #1 was reported as feeling better and no longer agitated. Under the section titled Psychological Risk, the document asks "Is the patient a risk to harm self or others?". The document indicated that the Hospitalist answered yes. There was no evidence that the attending psychiatrist was notified about this incident.

The Surveyor interviewed the Hospitalist on 6/6/19 at 11:00 A.M. The Hospitalist said she told the Psychiatry Team and they were aware of Patient #1's continued impulsive behavior on 5/16/19 (standing on a chair and banging on the window) and were going to re-evaluate him/her.

The Hospital document titled Psych Progress Note, signed by Resident #1 on 5/29/19 at 2:40 P.M., indicated that Psychiatry was asked to re-evaluate Patient #1 due to repeated non-compliance with non-weight bearing instruction by nursing staff. During the evaluation Patient #1 reported that the week prior he/she had a roommate that was so noisy he/she had thoughts of wanting to end his/her own life for a moment. Patient #1 reported that he/she hears a voice giving him/her instructions but that it occurred during sleep and that he/she has not been sleeping well.

The Surveyor interviewed the Psychiatry Attending on 6/6/19 at 11:25 A.M. The Psychiatry Attending said that he was originally asked to evaluate Patient #1 when he was admitted for delusions and paranoia. The Psychiatry Attending said that Patient #1's paranoia improved during his hospitalization with medication. The Psychiatry Attending said that Patient #1 no longer showed impulsive behavior and denied paranoid thoughts and was taken off 1:1 observation and no longer required an inpatient psychiatric bed. When asked about the incident when Patient #1 was standing on his/her chair and banging on the window, the Psychiatry Attending said that he was not aware that incident occurred. When asked about Patient #1's family's objections and stating that Patient #1 was still sharing paranoid thoughts with them, the Psychiatry Attending said that he was unaware that the family had reported that. The Psychiatry Attending said that he was unaware that the windows in Patient #1's hospital room could open. The Psychiatry Attending said that if he had known that the windows could open, he would have changed everything about how Patient #1 was cared for.