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 Oct. 30, 2019
VIOLATION: OPERATING ROOM POLICIES Tag No: A0951
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observations and interviews the Operating Room failed to consistently adhere to standards of care related to refrigeration of medication and discarding expired items.

The Surveyor toured the Operating Room and interviewed the Nurse Manage at 8:25 A.M. on 10/29/18.

The [DIAGNOSES REDACTED] (MH-is an emergency condition that triggers a severe reaction to certain drugs used as part of anesthesia) cart was reviewed with the Nurse Manager at 9:15 A.M. on 10/29/19. The Nurse Manager said that the cooled normal saline (a sterile mixture of salt and water for intravenous use) for a case of MH was kept in the refrigerator on top of the MH cart. The refrigerator had no thermometer to ensure that the intravenous solution was kept cool for a MH emergency.

The Surveyor examined equipment in the lithotripsy cart (a treatment typically using ultrasound shock waves, by which a kidney stone is broken into small particles that can be passed out of the body) at 9:15 A.M. on 10/29/19. Two sterile packs labeled "Stone Catcher" had both expired in June 2019. The Nurse Manager said this cart was rarely used anymore.