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Based on observation and staff interview, the Hospital failed to ensure that a safe environment was maintained for 3 of 4 household kitchens observed at the Hebrew Rehabilitation Center at Dedham to ensure all patients are cared for in a safe setting.


Findings include:

During tours on 7/23/14, the following concerns were observed:

1. On 7/23/14 at 8:00 A.M., the South Kitchen on the memory care floor, had an open floor plan and was easily accessible to all patients. This floor had patients who had a diagnosis of dementia and who were cognitively impaired. Two different unsecured draws contained large, sharp chef knives. The silverware draw was unsecured. The Southeast and Southwest Kitchens on the third floor had open floor plans and were easily accessible to all patients. The silverware draws were unsecured. A bottle of dish soap was out on the counter near the sink in each kitchen.

2. On 7/23/14 at 9:20 A.M., the South, Southwest and Southeast kitchen of the memory care floor had open floor plans and were easily accessible to all patients. All silverware draws were unsecured. The surveyor observed a patient wandering around the Southeast Kitchen, touching the covers of the steam table.

3. During an interview on 7/23/14 at 10:15 A.M. with the Executive Director of the Dedham campus, said the potential for injury to the patients existed because of the easy accessibility to the open kitchen areas. She agreed that the silverware, knives and dish soap could cause harm if handled incorrectly by a patient.

Based on record review and staff interview, the Hospital failed to conduct periodic appraisals of the medical staff or to include a specific delineation of privileges for three (3) of three (3) credential files reviewed.

Findings included:

1. The Surveyor reviewed the credential files of three (3) physicians (the Infection Control Chairperson, the Director of Respiratory Services, and a vendor Radiologist) on 7/28/14 at 10:00 A.M. The three (3) physician credential records did not contain evidence of a periodic performance appraisal. The Credential Coordinator said she was aware of the requirement to perform periodic appraisals, however, at the time these physicians were credentialed there was no system in place for periodic appraisals.

2. The delineation of clinical privileges is the process in which the medical staff
evaluates and recommends an individual practitioner to allow the practitioner to provide specific patient care services in the hospital using well-defined training criteria.

The Manager of Respiratory Therapy was interviewed at 9:00 A.M. on 7/28/14. The Manager said the Director of the Respiratory Therapy was a Pulmonary specialist who was able to intubate (place a breathing tube into the lungs) a patient as needed. Review of the Pulmonary specialist credential files failed to indicate any specific procedures (i.e. intubation) was included in his credentials.

Further review of the the Infection Control Chairperson, and the Vendor Radiologist credential files indicated the hospital failed to delineate the specific privileges/procedures the physicians were allowed to perform.

Based on record review and staff interview, the Hospital failed to ensure the care plan was comprehensive and included all patient care needs for 2 patients( #3 and #5) in a total sample of 62 patient records.

Findings include:

1. The current Hospital policy titled "Ventilator Management Guidelines" indicated the position of a patient receiving mechanical ventilation (Respirator) was to elevate the head-of-the-bed to 30-45 degrees unless ordered otherwise.

For Patient #3, admitted with a diagnosis that included respiratory failure, the Hospital failed to ensure that the patient's plan of care included the intervention of keeping the head of the patient's bed elevated at 30 degrees to reduce the risk of acquiring a ventilator associated pneumonia.

Medical record review on 7/22/14, indicated that Patient #3's plan of care did not include the intervention of maintaining a semi-recumbent position (30 degrees elevation of the head of the bed) as recommended in 2008 by the Centers for Disease Control and Prevention.

2. For Patient #5, the Hospital failed to ensure that the patient's plan of care included his/her care needs related to blindness.

Medical record review on 7/22/14, indicated that Patient #5 was admitted on 9/11/13 for acute and chronic respiratory failure.

Patient #5's problem list, (the basis of a patient's care plan), on 7/22/14, indicated the patient's blindness was not on the list.

During interview on 7/22/14 at 10:30 A.M., the Clinical Nurse Specialist said that the problem list should include that Patient #5 was legally blind and the nursing interventions to care for the patient.

Based on procedure review and interview with the laboratory director on 7/21/14 at 1:45 PM, the facility failed to ensure the Policy "Recalls, Market Withdrawals, Look Back and Notification of Adverse Effects of Transfusion" included all the criteria outlined in §482.27 (b) Potentially Infectious Blood/Blood Products.

Findings included :

On 7/21/14, the surveyor reviewed the facility document for HIV/HCV Look Back titled "Recalls, Market Withdrawals, Look Back and Notification of Adverse Effects of Transfusion" provided by the laboratory director.

The policy did not include specific notification criteria with timeframes and content of notification as outlined in §482.27 (b).

The laboratory director confirmed that the policy did not include all the criteria outlined in §482.27 (b).

Based on observation and staff interview, the Hospital failed to consistently maintain the portable emergency suction machines in working condition in two (2) of six (6) household suction machines.

Findings included:

1.) The Surveyor observed the portable emergency suction machines at the Hebrew Rehabilitation Center at Dedham campus during the morning tour of the Floor 2 on 7/21/14. The emergency suction machine located on the Northeast and Northwest households/units was not assembled for immediate use and the necessary components (collection receptacle, extension tubing) to construct a functioning emergency suction machine was not on the carts and not readily available. The Operations Manager said suction was available in each patient room, however, the mobile suction units would be used for an emergency outside of the patient rooms (i.e. the group dining area).





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2.) The Hospital failed to ensure an acceptable level of quality and safety in the Dietary Department at the Hebrew Rehabilitation Center at Boston.

On 7/22/14 at 9:30 A.M., the Surveyor toured the Dietary Department with the Food Service Director (FSD) and Director of Support Services and made the following observations:

a) The Main Kitchen floor was not maintained in good repair to ensure safety. In the Baker's Room, the grout between the floor tiles was either missing or worn allowing water to remain in the spaces between the tiles. In the Dishmachine and Pot/Pan Sink Room, there were large areas of missing and/or worn grout between the floor tiles. In two areas, the floor tiles were removed and replaced with what appeared to be poured concrete. There were puddles of water on the floor in this area. An extension cord to a standing fan was lying on the wet floor. Staff removed the extension cord after surveyor inquired about the safety of this practice. In the Cart Wash Room, broken floor tiles were observed at the perimeter of the area.

On 7/23/14, review of the Board of Health Inspection Report dated 7/2/14 read: "improper maintenance of floors, provide floors in good repair".


b. The Main Kitchen ceiling was stained and discolored throughout the kitchen. In Meat Aisle 2 and in the Dishroom, the covers of two ceiling panels were peeling. In the Cart Wash Area, a ceiling panel was missing. The ceiling above the chemical cabinet was dust laden.

c. The Main Kitchen walls were not maintained in good repair. In the Dishroom, a section of ceramic wall tiles (approximately 15 tiles) were missing. The lower wall by the pot/pan sink had cracked or missing tiles. The wall behind the disposal unit was dirty and in poor repair. In the Cart Wash area, the covering to the wall board was peeling.

d. Not all kitchen equipment was maintained to ensure an acceptable level of quality.

-Two food tray delivery trucks had duct tape wrapped around the handles which prevented adequate cleaning of the equipment.
-The eye wash station in the dishroom had no caps which exposed the nozzles to moisture, dust and splash.
-The microwave oven had heavy food stains and a loose handle.
-A water hose in the Baker's Room had duct tape wrapped around a section of the hose to contain leaking. The FSD indicated that a new hose was needed.
-The Italian Ice freezer lid was in poor condition with insulation exposed.
-The hood light fixtures in the food preparation areas were dust laden.
-The gaskets of Refrigerators "B", "G" and "J" were dirty and /or torn.
-The blower covers in the Baker's refrigerator were dirty.
-The can opener base and blade were dirty.

Based on observation and staff interview, the Hospital failed to ensure adequate lighting in all food service areas in the Dietary Department at the Hebrew Rehabilitation Center at Boston.

Findings include:

1. On 7/22/14 at 9:30 A.M. the Surveyor toured the Dietary Department with the Food Service Director (FSD) and the Director of Support Services.

In the Main Kitchen, the following refrigerators had burnt out or non functioning light bulbs:

-Baker's Reach-in
-Meat Walk-in
-Dairy Walk-in
-Reach-in "H"
-Trayline Reach-in
-Cold Preparation Reach-in


2. On the units, two refrigerators had burnt out or non functioning light bulbs:

-2 East Refrigerator
-2 West Refrigerator


3. The FSD indicated the light bulbs would be replaced.

Based on observation, record review, and staff interview the Hospital failed to consistently maintain a sanitary environment and adhere to Infection Control practices including Center for Disease Control (CDC) standards and Occupational Safety and Heath Administration (OSHA) requirements.

Findings included:

According to the OSHA Bloodborne Pathogen Standard (1910.1030(d)(2)(i)) engineering and work practice controls shall be used to eliminate or minimize employee exposure to bloodborne pathogens. The Hospital Exposure Control Plan, revised 8/29/13, indicated contaminated sharps are discarded as soon as feasible into sharps containers.

1. The Surveyor observed the Dental Clinic at the Hebrew Rehabilitation Center at Boston at 12:05 P.M. on 7/22/14. Dental Assistant #1 said the tubex syringes were used for local oral anesthetics. Dental Assistant #1 said the tubex syringes were loaded with a cartridge of medication and a non-safety needle was screwed on to the tubex. Dental Assistant #1 said after use, the contaminated needle would be unscrewed from the tubex and disposed of. Because the needle lacked a safety device and employees would need to manually remove the needle from the tubex, this action placed employees at risk for a sharps injury and failed to meet the OSHA requirement for sharps safety which prohibits contaminated needles from being bent, recapped or removed.

2. The Surveyor observed finger stick glucose testing at the Hebrew Rehabilitation Center at Dedham on Floor 2 North, Patient #58, at 7:30 A.M. on 7/23/14. At the completion of the finger stick glucose test, RN #1 walked with the used sharp back to the household nurses station for disposal. Despite a possible distance of fifty (50) feet, RN #1 said there was only one sharps container per household unit. This practice failed to meet the OSHA requirement to dispose of contaminated sharps immediately or as soon as possible after use. Because engineering control are not readily available, i.e. sharps containers, the transport of a contaminated sharp to one central sharps container does not eliminate or minimize employee potential exposure to bloodborne pathogens.

3. The Surveyor observed two mobile phlebotomy carts at the Hebrew Rehabilitation Center at Dedham at 1:50 P.M. on 7/23/14. Phlebotomist #1 said the mobile carts were brought to the households to draw the patient's bloodwork. The mobile phlebotomy carts had two sharps containers that were unsecured with opened tops. Because the sharps containers were unsecured and contained contaminated items this created a risk of spill of biohazardous waste.

4. The Surveyor reviewed the CDC Guidelines for Preventing Healthcare Associated Pneumonia, 2003 and the current Hospital policy titled "Ventilator Management Guidelines". To minimize the risk of a Ventilator Associated Pneumonia (VAP), the position of a patient receiving mechanical ventilation (Respirator) required the elevation of the head-of-the-bed to 30-45 degrees unless ordered otherwise. The Surveyor observed one ventilated patient in bed at an undetermined height and interviewed the Manager of the Respiratory Therapy (RT)Department at 11:00 A.M. on 7/22/14. The RT manager said the beds that used by patients requiring a respirator did not have any device to measure the elevation of the head-of-the-bed position and the measurement was a guess. This practice did not comply with the Hospital policy or CDC practice guidelines, which both state precise measurement of 30 degrees or higher, to decrease the rates of ventilator pneumonia.

5. On 8/26/2010, the Centers for Disease Control (CDC) issued requirements for Infection Prevention during Blood Glucose Monitoring that state whenever possible, point of care (POC) blood testing devices (glucometers) should be used only on one patient and not shared. If dedicating a POC glucometer to a single patient is not possible, the devices should be properly cleaned and disinfected after every use as described in the device labeling. If the manufacturer does not specify how the device should be cleaned and disinfected then it should not be shared.

The Surveyor observed finger stick glucose testing at the Hebrew Rehabilitation Center at Dedham on Floor 2 North, Patient #58, at 7:30 A.M. on 7/23/14. At the completion of the procedure, RN #1 said the shared glucometer device is cleaned monthly instead of between each patient use.

6. According to the CDC 2007 Guideline for Isolation Precautions in Healthcare Settings, the hospital provides instructional materials for patients and visitors on recommended hand hygiene and the application of Transmission-Based Precautions.

The Surveyor observed the contact precaution signage at the Hebrew Rehabilitation Center at Dedham on numerous patient's doors during the household/unit tours on 7/21/14. The signage was designed to resemble art work with a decorative design covering approximately 75% of the sign. The signage did not provide detailed instruction on the use and disposal of personal protective equipment (PPE), nor did it direct visitors on the specific selection of PPE. The signage provided no compensatory features to assist a non-English speaking visitor (i.e. an illustration of the necessary PPE) and did not ask that visitors report to the nurse before entering the contact precaution room.

7. The Surveyor interviewed a private caregiver at the Hebrew Rehabilitation Center at Dedham at 4:50 P.M. on 7/23/2014. The private caregiver said she was hired by a patient's family to act as a companion for Non-sampled Patient #1 (NS #1). The private caregiver said she connected with NS #1's family through an on-line internet service where the private caregiver posted her availability. The private caregiver said she was on duty for fifty six (56) hours each week. The private caregiver said she had no knowledge of infection control practices nor did she receive prior screening. The private caregiver was observed at the group dining table with NS #1 and other patients from the household/unit.

The Surveyor interviewed the Executive Director of the Hebrew Rehabilitation Center at Dedham in the afternoon on 7/23/14. The Executive Director said many of the patients or the patient's families do hire private caregivers to attend to patients. The Executive Director said after consultation with the Hospitals legal advisors, these caregivers are considered visitors although these caregivers are onsite for in excess of 40 hours a week interacting with patients during their care duties. As visitors, the Executive Director said the Hospital did not have any policies or procedures relating to infection control in place to address these private caregivers.



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8. During the tours of 3 North, 3 South and 4 North corridors of the MACU (Medical Acute Care Unit) at Hebrew Rehabilitation Center on 7/24/14 at 8:30 A.M. and the 4 North corridor of the MACU on 7/24/14 at 2:15 P.M., the Hospital failed to maintain 15 precaution carts on the 3 North, 3 South and 4 North corridors, such that the precaution carts could be appropriately disinfected or sanitized to prevent the spread of infection, the Surveyor observed:

a.) On the 3 South corridor there were 6 precaution carts. All 6 precaution carts contained too numerous to count pieces of scotch tape and tape residue on the top outside surface and on the front of the 3 storage drawers which was unable to be cleaned properly. Two of the six precaution carts had broken and missing pieces of plastic cabinetry on the top ridge piece of the precaution carts.
b.) On the 3 North corridor there were 5 precaution carts. All 5 precaution carts contained multiple pieces of scotch tape and tape residue on the top outside surface and on the front of the 3 storage drawers which was unable to be cleaned properly. Two of the five precaution carts had broken and missing pieces of plastic cabinetry on the top ridge piece of the precaution carts.
c.) On the 4 North corridor there were 4 precaution carts. All 4 precaution carts contained too numerous to count pieces of scotch tape and tape residue on the top outside surface and on the front of the 3 storage drawers which was unable to be properly cleaned and sanitized.
d.) The Surveyor interviewed the MACU Program Director at 2:30 P.M. on 7/24/14. The MACU Program Director said she was aware of the problems with the precaution carts and that she was in the process to find replacements. The MACU Program Director said the first 2 replacement options she evaluated were not the right replacement options for her unit.




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9. The dietary department at Hebrew Rehabilitation Center at Dedham, failed to ensure sanitary practices were maintained when storing equipment used for food preparation, cooking and serving.

During a tour of the main kitchen on 7/21/14 at 1:30 P.M., the following was observed:

-Two small robot coupes (food processors) were stored upright and covered. Both had free standing water inside them.

-More than ten different sized cooking pans and sheet pans were visibly wet and stacked together on a clean equipment rack.

During a tour of the Kosher Kitchen (on the Dedham campus) on 7/22/14 at 11:00 A.M., the following was observed:

-Four full sheets pans, three steaming pans and five full sized pans were visibly wet and stacked together on a clean equipment rack. Water was pooled in the edges of the pans and they were wet to the touch when separated.

During a second tour of the main kitchen on 7/24/14 at 9:20 A.M., the following was observed:

-Six sheet pans, two plastic food storage containers, five quarter, four half, and five full sized pans were visibly wet and stacked together on the clean equipment racks.

During an interview with the Executive Director of Dietary and the Executive Chef on 7/24/14 at 9:35 A.M., said the equipment should not be stacked and stored together wet. Both said they understood the increased risk of food borne infections when equipment was not adequately dried before being stored.



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10. The dietary department at Hebrew Rehabilitation
Center at Boston failed to ensure sanitary practices were maintained when serving ice, identifying and dating refrigerated foods and proper cleaning and santizing of drinking water dispensers.

During a tour of the main kitchen on 7/22/14 at 9:30 A.M. with the Food Service Director (FSD), the following was observed:

a) The ice scoop for the ice machine in the Main Kitchen was stored on top of the the ice machine. The ice scoop was not stored in a clean ice scoop holder to protect the scoop from dust, splash and moisture.

b) Refrigerated foods were not always identified and dated as per the Hospital policy that read: "Identify and date refrigerated food storage items".

-In the Cold Food Preparation area, the refrigerator had a container of egg salad that was not dated. The FSD indicated that the egg salad was prepared the day before.

-In Reach-In "A", the pickled herring was not identified and dated.

-In Walk-In #1, a container of gravy was not identified; a pan of boiled chicken was not dated. A pan with turkey and a pan with stir fry was not identified and dated.

-In Walk-In #3, a container of Hummus was not identified and dated.

11. On 7/22/14 at 2:15 P.M., the Surveyor toured the Nourishment Kitchens on the patient care units with the FSD.

The Surveyor observed non disposable dispensers of drinking water on the units. The Surveyor inquired how the water dispensers are cleaned.

The Unit Manager on the Berenson West Unit showed the Surveyor a bottle of dish detergent used to wash the dispensers on the unit.

The FSD indicated that the dispensers are not sent through the dishmachine or the 3 bay sink for washing, rinsing and sanitizing.

The FSD indicated that a change in procedure would be made to ensure the dispensers are washed, rinsed and sanitized appropriately.










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Based on staff interviews, record review and policy review, for 4 of 8 records( #52, #53, #54 and #55), the Hospital failed to ensure that the family or the potential donor was informed of their option to donate organs, tissues, or eyes, or to decline to donate.

Findings include:

1. Review of the Hospital policy titled Organ and Tissue Donation Policy revised 6/9/14, indicated that at the time of admission, Social Services will inquire if the patient has an organ donor card or is registered as an organ donor on their driver's license. This organ donor request form (Appendix B) is placed in the patient's medical record.

Review of Appendix B - Organ Donation Request Form indicated that the purpose of the form was to "identify your wishes regarding organ and tissue donation." The Appendix B form offered individuals the opportunity to check a box indicating they "do not want to be an organ and tissue donor."

2. Patient Records #52 #53, #54 and #55 indicated that these 4 Patients had either no Appendix B form in the chart or had another form not covered by the policy.

Patient #52 and #55 had no Organ Donation Request Form [Appendix B] in their medical record.

Patient #53 and Patient #54 had a form titled Organ Donation that was not authorized in the policy and did not specify the patient's wishes - there was only a zero with a line through it or an X with the patient's name and no date on the form.

3. Interview with the Social Services staff on 7/24/14 at 10:00 A.M., the Administrator on 7/24/14 at 12:45 A.M. and the VP of Quality and Regulatory Affairs on 7/23/14 at 11:00 A.M., indicated that the procedure for assessing if the patient wishes to be an organ/tissue donor is conducted by the Social Worker on admission. Appendix B is to be filled out with the appropriate box checked as to the wishes of the patient for organ donation. The Social Worker, Administrator and the VP for Quality and Regulatory Affairs all acknowledged that Appendix B was not consistently filled out and therefore, the wishes of the patient regarding organ donation was not established.

Based on review of documentation, interviews and the Hospital's educational program titled "Organ and Tissue Donation: Policy Review," the Hospital failed to ensure that the Social Workers who are responsible for obtaining the Organ Donation status of new patients on admission had completed the Hospital's program on the donation policy.

Findings include:

1. Two Social Workers (SW #1, SW #2 ) who are assigned to Patient care units at the Hebrew Rehabilitation Center at Dedham Campus were interviewed on 7/24/14 at 10:00 A.M. Both Social Workers confirmed that it is Social Service's responsibility to obtain a newly admitted Patient's donor status. One Social Worker was assigned to the RSU/Memory Support Unit and the other was assigned to the 2nd floor Long Term Care Unit. Both Social Workers meet with newly admitted Patients regarding their their wishes for Organ Donation. Both Social Workers said they had not completed the Hospital's educational program for Organ and Tissue Donation.

2. The Administrator was interviewed on 7/24/14 at 12:45 P.M. The Administrator was not aware that both Social Workers had not completed the Hospital's training program for Organ Donation. The Administrator acknowledged that the Social Workers will need to complete the Hospital's training program for organ donation.