HospitalInspections.org

Condition of Participation: Quality Assessment and Performance Improvement Program was out of compliance.

Findings included:

The Hospital failed to ensure they conducted thorough investigations and monitored the effectiveness and safety of services and quality of care to Hospital patients.

Refer to TAG: A-0273.

The Hospital failed for to ensure corrective actions were investigated following an identified opportunity for improvement.

Refer to TAG: 0283.

The Condition of Participation Nursing Services was out of compliance.

Findings included:

1.) The Hospital failed to have a well-organized Nursing Service with administrative authority, delineation of nursing responsibilities for patient care, including determining nursing personnel to provide nursing care for all areas of the Hospital. Nursing Services failed to ensure the Hospital's Nursing Service evaluated Registered Nurse (RN) #2 and RN #3 for their quality of care proved to Hospital patients in an Outpatient Service.

Refer to TAG: A-0386.

2.) Nursing Services failed to ensure nursing personnel performance to provide nursing care to all patients as needed.

Refer to TAG: A-0392.

3.) The Hospital failed to ensure they provided nursing care supervision in accordance with effective fall prevention care, resulting in an unwitnessed fall.

Refer to TAG: A-0396.

4.) The Hospital failed to ensure that medications were administered according to acceptable standards of practice.

Refer to TAG: A-0405.

The Condition of Participation: Infection Prevention & Control and Antiobiotic Stewardship was out of compliance;

Findings included:

The Hospital failed to ensure Infection Prevention activities.

Refer to TAG: 0749.

The Condition of Participation: Outpatient Services was not met.

Findings included:

1.) The Hospital failed to ensure Outpatient Services were organized and integrated with Hebrew Rehabilitation Center (Hospital), Inpatient Services.

Refer to TAG: 1077.

2.) The Hospital failed to assign one or more individuals responsible for Outpatient Services, based on scope and complexity, necessary to direct the Outpatient Services for which they were responsible.

Refer to TAG: 1079.

Based on records reviewed and interview, the Hospital failed for one patient (Patient #41), in a sample of sixty-five patients to ensure staff followed the policy and procedure for restraint assessment after application of mitt restraints.

Findings included:

Review of the Hospital policy titled, Restraints, dated as revised 2/7/2022, indicated:

-The licensed Nurse was responsible for the ongoing assessment of the patient's safety, behavioral and psychological status including evaluating the effectiveness of alternative measures, signs of injury, skin issues, circulation, physical and psychological state/comfort, readiness of discontinuation of restraints and correct body alignment,

-Every two hours the Nurse was responsible to offer nutrition, fluids, hygiene, toileting and range of motion; and the Nurse was responsible to release a minimum of one restrained limb, and

-The Nurse shall document an assessment at least every two hours.

The medical record indicated Patient #41 was admitted in 4/2021, with the diagnoses that included status post Covid -19 with placement of a tracheostomy (surgically created opening into the windpipe to allow direct access to a breathing tube), percutaneous endoscopic gastrostomy (PEG) tube placement (tube inserted through the wall of the abdomen directly into the stomach to provide a means of feeding) and End Stage Renal Disease on hemodialysis.

The Physician note, dated 4/2/21, indicated Patient #41 frequently attempted to pull out the PEG tube and tracheostomy. The Physician note indicated the Patient's Health Care Proxy was activated due to Patient's decline in mental status.

The Physician's orders for Restraint, dated as initiated 4/2/21 and ordered daily through 4/7/21, indicated the use of bilateral hand mitts for Patient's safety due to potential to harm self by removing medical devices.

The Restraint Assessment Documentation, dated 4/2/21 through 4/7/21, indicated the following dated and timed consecutive entries were not documented at least every two hours per the restraint policy:

4/4/21: 06:00, 11:23, 15:23
4/5/21: 14:00, 17:00
4/6/21: 13:23, 17:00

The medical record indicated on 4/7/21, Patient #41 had a decline in medical status and was transferred to a local emergency room for treatment and admission. Patient #41 was readmitted to the Hospital on 4/17/21 and the Health Care Proxy remained in place due to Patient's decline in mental status.

Review of the Physician's note, dated 4/18/21, indicated Patient #41 was attempting to pull at, and remove medical devices.

Review of the Physician's order for Restraint, initiated 4/18/21 and ordered daily through 4/21/21, indicated the use of a left-hand mitt for Patient's safety due to potential to harm self by removing medical devices.

Review of the Restraint Assessment Documentation, dated 4/18/21 through 4/22/21, indicated the following dated and timed consecutive entries were not documented at least every two hours per the Restraint policy:

4/19/21: 14:00, 18:12
4/20/21: 06:00, 12:00
4/20/21: 15:00, 19:00
4/21/21: 11:37, 14:39

Subsequent review of the medical record indicated, on 4/22/21, Patient #41 had a decline in medical status and was transferred to a local emergency room for treatment and admission.

During an interview, on 3/11/22 at 7:39 A.M., the Chief Nursing Officer said staff should document assessments as indicated in the Hospital policy.

Based on records reviewed and interviews the Hospital failed to ensure they conducted thorough investigations and monitored the effectiveness and safety of services and quality of care to Hospital patients.

Findings included:

1.) The Hospital failed to integrate Outpatient Services into its Quality Assessment and Performance Improvement Program.

During the interview, at 12:30 P.M. on 3/10/2022, the Medical Director said the clinic (Hebrew SeniorLife Medical Group at Orchard Cove) did not participate in the Hospital's Quality Improvement Program.

2.) The Hospital failed to integrate monitoring of Contracted Services into its Quality Assessment and Performance Improvement Program.

The documents titled:

- Mobilexusa Portable Diagnostic Services Agreement, dated 6/2015, indicated a contracted service between Hebrew Rehabilitation Center at Newbridge on the Charles and Symphony Diagnostic Services No. 1, Inc., for portable x-ray, cardiac and ultrasound services.

- In-House Dialysis Services Agreement, dated 1/1/2019, indicated a contracted service between Bio-Medical Applications of Massachusetts, an affiliate of Fresenius Medical Care Holdings, Inc. and Hebrew Rehabilitation Center for dialysis treatments. The titled In-House Dialysis Services Agreement indicated it was a draft.

During the interview, at 11:30 on 3/11/2022, the President said someone forgot to remove the draft watermark (the draft wording).

-Brewster Ambulance Service, dated 1/15/2020, indicated a contracted service between Brewster Ambulance Company and Hebrew SeniorLife, Inc (thereafter Facility) for ambulance transport services.

-Agreement for Provision of Blood Components and Related Services, dated 1/2011, indicated a contracted service between Steward St. Elizabeth's Medical Center of Boston, Inc and Hebrew Rehabilitation Center for blood.

-Service Agreement, dated 11/9/2018, indicated a contracted service between Crothall Facilities Management, Inc and Hebrew SeniorLife, Inc. for service to equipment.

-Third Amendment to Service Agreement Between Hebrew Rehabilitation Center and Crothall Healthcare, Inc., dated 5/15/2014, indicated a contracted service for linen services.

-Vascular Services Agreement, dated 6/2012, indicated a contracted service between First Response Clinical Services, LLC and Hebrew Rehabilitation Center for insertion of Peripherally Inserted Central Catheter line placements.

The Hospital provided no documentation to indicate monitoring of Contracted Services for the quality of care provided to Hospital patients.

During the interview, at 11:00 A.M. on 3/9/2022, Vice President for Skilled Nursing and Hospital Operations said the Quality Meetings for the Hospital and Skilled Nursing Units were combined, however no Outpatient Services quality indicators were discussed or identified.

3.) Hospital internal investigations, dated 3/11/2021 and dated 3/29/2021, regarding medication errors indicated no documentation of monitoring corrective actions for improvements in the quality of patient care.

4.) The Hospital failed to implement a thorough investigation regarding Patient #46's complaint.

During the interview, at 1:30 P.M. on 3/8/2022, Patient #46 said that he/she was a quadriplegic (paralyzed in four extremities) and that the mechanical lift required to lift him/her from the bed to a motorized wheelchair and back was not always functioning properly, and Patient #46 had complained to staff. Patient #46 said the nurses had to lift him/her manually and he/she felt worried someone would get hurt.

During the interview at 4:00 P.M. on 3/8/2022, the Associate Chief Nursing Officer (ACNO) said she was aware of Patient #46's complaint about the lift but and she had records indicating the lift was working properly. The ACNO said the lift was maintained through a Contracted Service and no maintenance logs were kept at the Hospital. The Hospital provided no record of maintenance following Surveyor request.

The Hospital document titled Concern Resolution Report Dedham LTCH, undated, indicated no documentation of a written complaint from Patient #46 during the period of 3/8/2021 through 3/8/2022.

During an interview, at 9:00 A.M. on 3/11/2022, Patient #46 said he/she reported the issues regarding a non-functional ceiling lift to direct care staff and was not aware that he/she could file a formal complaint with the Hospital.

The Surveyor observed, at 9:00 A. M., on 3/11/2022, the ceiling lift (a patient lifting device) in Patient #46's room had a red-light illuminated next to a symbol of a wrench, the ceiling lift had a blue label on it titled Crothall Healthcare Inspected with the date completed written as 3/21 and the date due as 3/22.

The Surveyor observed, at 10:00 A.M. on 3/11/2022, in the second floor clean supply closet a battery charging log for the ceiling lift; the log sheet indicated the instructions as Important-charge battery each shift each day even if lift was not used on your shift; the Surveyor observed the log was not signed each shift, each day. The Surveyor observed an outdated inspection sticker on Patient #46's Bed; the Hospital bed in Patient #46's room indicated a Bed Scheduled Maintenance Inspected in 8/17, and re-Inspection dated 8/18 Biomed (undefined).

The Hospital provided no resolution to Patient #46's complaint. The Hospital provided no thorough investigation includeing resolution regarding Patient #46's complaint of the non-functioning patient lift equipment.

Based on observations, records reviewed and interview the Hospital failed for one patient (Patient #46) in a sample of sixty-five patients to ensure corrective actions were investigated following an identified opportunity for improvement.

Findings included:

During the interview, at 9:00 A.M. on 3/11/2022, Patient #46 said he/she did not know who cleaned his/her Continuous Positive Airway Pressure (CPAP) machine, he/she said he/she did not know the last time the CPAP machine was cleaned, and he/she said the water that was put into the CPAP machine was on the lowest shelf on his/her bookcase.

The Surveyor observed, at 9:00 A.M. on 3/11/2022, a gallon jug labeled Poland Spring distilled water, undated, with approximately half volume clear liquid inside, on the lowest shelf of the Patient #46's bookcase. Patient #46 said this was the water used in the CPAP machine.

During the interview, at 1:00 P.M on 3/15/2022, the Associate Chief Nursing Officer (ACNO) said the Hospital had a policy on the cleaning CPAP equipment; however there was no area to document when the cleaning was done. The ACNO said this was monitored during the Charge Nurse rounding but was not recorded. The ACNO said there was not a Respiratory Therapist on staff at the Hospital's Dedham Campus, therefore the Nurses set up the CPAP machines and a Nurse Manager would make a telephone call to the Hospital's Roslindale Campus to ask the Respiratory Therapist if the machine was set up correctly. The ACNO said the Respiratory Therapist did not come to (Respiratory Therapy care at) the Dedham Campus. The ACNO said this was a problem.

The Hospital did not provide a Hospital Policy on the cleaning of CPAP equipment. The Hospital provided no corrective action plan regarding this identified patient care need.

Based on records reviewed the Hospital Medical Staff failed for two patients (Patients #46 and #50) in a sample of sixty-five patients to ensure clear Physician orders.

Findings included:

Regarding Patient #46:

A Nursing Note, dated 10/27/2021, indicated Patient #46's breathing was assisted by 2 Liters of supplemental oxygen and CPAP (machine that pushes air into patient's lungs using a single pressure). Doctors' orders indicated no indication for Patient #46 to receive supplemental oxygen.

Patient #46's medical record indicated no documentation of changing from BiPAP to CPAP until 2/4/2022 (four months later).

During the interview, at 9:30 A.M. on 3/11/2022, the Nurse Manager said that Physicians ordered oxygen.

Regarding Patient #50:

Physicians' Orders, dated 11/18/2021, indicated Patient #50's vital signs to be monitored every eight hours for 12 (undefined) and every 28 days (undefined).

Physicians' Orders, dated 12/13/2021, indicated a Patient #50's vital signs to be monitored daily; the Physician's Orders indicated no documentation to discontinue the previous vital sign order or 11/18/2021.

Vital Sign Flow Sheet indicated Patient #50's vital signs were monitored on 2/16/22, 2/23/2022, 3/2/2022 and 3/9/2022 and inconsistent with either Physician Order.

Physician's Orders indicated no clarity for Nursing Services to monitor Patient #50's vital signs.

Based on records reviewed and interviews the Hospital failed to have a well-organized Nursing Service with administrative authority, delineation of nursing responsibilities for patient care, including determining nursing personnel to provide nursing care for all areas of the Hospital. Nursing Services failed to ensure the Hospital's Nursing Service evaluated Registered Nurse (RN) #2 and RN #3 for their quality of care proved to Hospital patients in an Outpatient Service.

Findings included:

The Job Description titled Staff Nurse LPN/ RN, dated, 4/2020, indicated Registered Nurses reported to the Director Nursing.

Regarding RN #2:

RN #2 personnel file indicated she was a Registered Nurse.

The document titled Hebrew SeniorLife Goals and Progress Summary, dated 10/7/2021, indicated RN #2. The Goals and Progress Summary indicated RN #s's quality of nursing care was not evaluated within the Nursing Service. Refer to TAG: 1079.

Regarding RN #3:

The document titled Hebrew SeniorLife Goals and Progress Summary, dated 8/30/2021, indicated RN #3 as employed as a Patient Clinic Nurse Supervisor for the LTCH (Long-Term Chronic Hospital, Hebrew Rehabilitation Center) The Goals and Progress Summary indicated RN #3's quality of nursing care was not evaluated within the Nursing Service.

During the interview at 3:00 P.M. on 3/10/2022, the Chief Nursing Officer said that Administrative Director (of the Medical Staff) was responsible for providing Outpatient Registered Nurses their performance evaluations; the Chief Nursing Officer said she did not know who was responsible for evaluating the Outpatient Registered Nurse's nursing practice (as the Administrative Director was not a nurse).

Based on observations and interview the Nursing Services failed to ensure nursing personnel performance to provide nursing care to all patients as needed.

Findings included:

The Hospital Policy titled Patient Care Services Code Blue, dated 5/24/2021, indicated an AED (Automated External Defibrillator) was included as necessary equipment of Emergency Carts.

During the interview, at 11:15 A. M. on 3/8/22, RN #5 said she did not know what the AED was; RN #5 said she did not know how to open it (necessary action to operate it); RN #5 said she did not know where the pads (part of the AED) were located; and RN #5 said it was part of the code cart.

The Hospital failed to ensure RN #5 could demonstrate use of an AED when requested by the Surveyor, to establish personnel performance to provide nursing care to patients requiring emergency care.

Based on observation, staff interview and record review, the hospital failed to ensure that medications were administered according to acceptable standards of practice for two patients (Patient #26 & #46), in a total sample of sixty-four patients.

Findings include:

Regarding Patient # 26

On 3/9/22, on the Berger 5 North unit, medication administration was observed with Nurse # 1. Patient # 26 received Levothyroxine Sodium 37.5 milligrams at 8:50 A.M., along with several other medications. The Patient had finished his breakfast just prior to receiving this medication.

According to the American Society of Health-System Pharmacists, (ASHP), this medication is to be administered on an empty stomach, between 30 minutes to one hour prior to eating. Giving this on a full stomach may interfere with proper absorption of this medication.

Nurse #1 said she always gives this medicine, along with other morning medications, around this time each day. Patient receives and eats his breakfast every morning around 8:15-8:30 A.M.





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Regarding Patient #46:

A.) The Hospital Patient Care Services Policy titled Preparing Patient Medication for Off Campus Visit, dated 12/4/2019, indicated a health care provider's order was ordered at least 48 hours prior to the start of the off-campus visit. The Preparing Patient Medication for Off Campus Visit policy indicated, when a controlled substance was needed, the Pharmacy would provide a Take-Home Medication Controlled Substance Form with the following information:

-patient's name and floor,

-Name of medication dispensed and total amount used, and

-Signature of Nurse receiving controlled substances and the Pharmacist issuing controlled substances.

The Hospital Policy titled Preparing Patient Medication for Off Campus Visit, dated 12/4/2019, indicated the family was given instructions on how and when the medication was given, and before leaving, an Authorization for Releasing and Returning Medications form was signed by the responsible family member and the nurse indicating the medication instruction.
Nursing Note, dated 8/20/2021 at 2:17 P.M., indicated Patient #46 had departed the Hospital with plans to return at 3:00 P.M., the Nursing note indicated Patient #46 departed the Hospital with a dose of Lyrica (anticonvulsant, controlled substance prescribed for pain, with a potential for substance abuse and addiction) scheduled at 3:00 P.M. that day and this was cleared by Pharmacy; the Nursing Note indicated Patient #46 was educated on administration and timing of the medication.

Patient #46's medical record indicated no indication of a provider order at least 48 hours prior to the Off-Campus visit; Patient #46's medical record did not indicate it included the Take-Home Medication Controlled Substance Form.

B.) The Hospital Patient Care Services Policy titled Guidelines for Completing Event Reports, dated 2/23/2022, indicated actual or potential medication errors were reported, the event follow-up included that managers identified issues, noted actions taken, and signed off at the completion of investigation.

Nursing Note, dated 8/15/2021 at 6:41 P.M., indicated Patient #46 received 100 mgs of Lyrica (anticonvulsant medication, with sedation side effects) instead of 50 mgs. The Nursing Note indicated Patient #46 was informed and monitored.

The document titled Hospital Reports, dated 3/8/2021 through 3/8/2022, indicated no medication events regarding Patient #46 for 8/15/2021, consistent with Hospital policy.

Based on records reviewed and interview the Hospital failed for two patients (Patient #52 & #65) in a sample of sixty-five patients to ensure all patient medical record provider orders were authenticated in written or electronic form by the person responsible for providing or evaluating the service provided.

Findings included:

Regarding Patient #52:

Patient #52 Medical Record Review, indicated an active Physician Order for the patient weight to be measured every 28 days at 8:00 A.M., the order was dated 10/17/2011 and written by a Physician no longer working at the Hospital.

Physician Order, dated 10/17/2011, indicated an order to monitor Patient #52's weight every 28 days.

During the interview, at 9:17 A.M. on 4/6/2022, the Vice President for Operations said the Physician was no longer worked at the Hospital.

Regarding Patient #65:

During the interview, at 11:30 A.M. on 3/11/2022, the Chief Nursing Officer said that when the Physician was no longer her (credentialed at the Hospital) there was no process for reordering (patient) orders. The Chief Nursing Officer said that the process for reordering Nurse Practitioner and Physician orders was unclear and that she believed it was an automatic (electronic medical record) process.

Patient ##65's medical record indicated a respiratory therapy order for Patient #65's started on 10/29/2019 and was still active over two years four months later, at the time of the Survey.

During the interview, at 3:10 P.M. on 3/10/2022, the Informatics Nurse said the physician who placed this active respiratory therapy order was no longer with the Hospital.

The Informatics Nurse said that a documentation limitation in the Electronic Medical Record (EMR) does not allow for the renewal nor a stop time for all non-medication orders, (medication orders do have a start/stop time as well as the ability to be renewed). Non-medication orders have a start time but no stop time and thus continue indefinitely unless manually discontinued. Non-medication orders include but may not be limited to: nursing related orders (i.e. Vitals, Weights, Treatments, Skin, Catheter, Neurology), respiratory therapy orders, physical therapy/occupational therapy orders, and diet orders. The Informatics Nurse said the Hospital had patients that were admitted/reside at the Hospital for extended periods of time (months or even years). Informatics Nurse said patients may reside at the Hospital beyond the tenure of an ordering physician. Informatics Nurse said as a result, the non-medication orders of the physician who had left the Hospital were maintained in the patient's electronic medical record and continued if determined applicable by the new physician who took over care for the patient. The Informatics Nurse said due to the lack of a renewal function and the lack of a stop time on all non-medication orders, it would be extremely time consuming to have to discontinue and re-order all previous departing physician orders, as the departing physician may have had multiple orders written for multiple patients during the physician's tenure at the Hospital. The Informatics Nurse said the Hospital had patients that have active orders (i.e. RT, nursing orders) in the EMR system written under physician(s) who no longer practiced at the Hospital and thus no longer are part of the active credentialed Medical Staff of the Hospital.

The Hospital provided no corrective actions to ensure all patient medical record provider orders were authenticated in written or electronic form by the person responsible for providing or evaluating the service provided.

The Surveyor made the following observations of the Hospital pharmacy cleanroom during inpatient pharmacy observations, conducted on 03/08/2022.

Findings included:

1.) The cleanroom did not have hand sanitizer (or some form of acceptable alcohol based surgical hand scrub) in the applicable cleanroom spaces.

2.) The cleanroom had wide gaps between the door and floor of the door between the non-hazardous buffer room and the anteroom, as well as between the anteroom and the adjacent space, (approximately 3 inches in height). Also, gaps of space were identified between the buffer room walls and the floor and the anteroom walls and the floor.

3.) A hole was identified in the chair located in the buffer room. Dirt was also identified towards the bottom of the chair above the wheels.

4.) The Primary Engineering Control (PEC, also known as a hood where sterile compounding is performed) had a solid row of rust running across the hood from left to right.

5.) The temperature of the non-hazardous buffer room was observed to reach 70.9 °F.

6.) During the hand hygiene and garbing process, the surveyor observed the pharmacy technician performing the hand washing stage prior to donning shoe covers, face mask and the bouffant cap.

7.) The PEC (hood) certification that verifies functionality of the hood failed to have a non-viable particle count test done inside the compounding area of the hood.

Based on observation and interview, the Hospital failed to maintain a dishmachine in safe operating condition on one unit at the Dedham campus.

Findings included:

During an observation, on 3/9/22 at 8:45 A.M., the dishmachine on the one north unit was leaking through the bottom, which subsequently was causing the floor tiles to lift off the floor.

During the interview, on 3/9/22 at 11:00 A.M., a staff member on the unit said that she would usually report damages to the engineering department and there was a computer system to enter the repair request. The staff member said she was not aware the dishmachine was broken.

Based on observations, records reviewed and interviews the Hospital failed for one patient (Patient #23) in a sample of sixty-five patients to ensure Infection Prevention activities.

A.) Based on observation and interview the Hospital failed for two kitchens to ensure labeling and dating of food items and appropriate storage of raw food items.

Findings included:

The Hospital policy titled Food and Supply Storage, undated, indicated the following:

- In refrigerators, stored cooked food above fresh foods to prevent cross contamination. All raw meat, poultry, fish, and eggs would be stored on the bottom shelves,

- Food products that were opened and not completely used or prepared at the facility and stored, the food product contents and preparation and use by dates would be labeled,

The Surveyor observed in the Roslindale campus kitchen, on 3/8/22 at 11:16 A.M., the following inconsistencies with Hospital policy:

- A bottle of Ken's sweet and sour sauce was expired on 12/20/21.

- A bag of mozzarella cheese was undated and unlabeled in the refrigerator.

- A container of raw chicken tenders was undated, unlabeled in the walk-through refrigerator.

- A pan of brisket was not fully wrapped in the freezer and had freezer burn on it.

- An uncovered hotel pan of food was located in the freezer.

- A package of English muffins was on the freezer floor.

- A large jar of pickles was undated and unlabeled in the walk-in produce cooler.

The Surveyor observed in the Dedham campus kitchen, on 3/9/22 at 9:30 A.M., the following inconsistencies with Hospital policy:

- Raw beef was being stored over cooked chicken on a cooling rack in the walk-in refrigerator.

- A container of blue cheese was open and undated.

- A container of yogurt and cottage cheese was opened and undated in the dairy fridge.

- A container of chocolate ganache was labled 2/20/22.

- A container of caramel was labeled 1/25/22.

- Raw salmon was being stored over cooked burgers in the walk-in refrigerator.

During an interview, on 3/9/22 at 9:38 A.M., the Executive Chef said the policy was to only keep items in the refrigerator for five days.


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B.) The Hospital failed, for Patient #23, to provide infection control measures to prevent potential bladder infections related to poor urinary catheter care.

The Hospital policy titled "Urinary Catheter: Indwelling (Foley) Catheter Care", dated 7/29/21, indicated the collection chamber [bag] should not be allowed to rest on the floor.

Review of Patient #23's physician order, dated 2/25/22, indicated Patient #23 required a urinary Foley catheter for urinary retention.

The Surveyor observed, on 3/8/22 at 11:54 A.M., Patient #23 with the urinary catheter, tubing and bag connected to Patient #23, and the urinary bag placed on a towel on the floor beside Patient #23's bed. At 11:58 A.M., a nurse's aide entered Patient #23's bedroom, standing next to the urinary bag, located on the floor, and did not remove the bag from the floor.

The Surveyor observed, on 3/9/22 at 1:44 P.M., the urinary bag of Patient #23's bedroom floor. At approximately 1:46 P.M., a nurse's aide entered the bedroom, spoke with Patient #23 and did not remove the urinary bag from the floor.

During an interview, on 3/9/22 at 1:48 P.M., the Unit Manager said the urinary bag was on the floor because the hook for the bag did not fit properly onto the bedframe.

During an interview, on 3/10/22 at 1:20 P.M., with the Infection Preventionist, she said it was not best nursing practice to leave a urinary catheter bag and tubing on the floor due to an increased risk for contamination and infection.








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C.) Based on observations records reviewed and interviews the Hospital failed to ensure Infection Prevention activities.

The Surveyor observed, at 10:00 A.M. on 3/11/2022, in a clean supply closet on the second-floor patient care unit, a plastic box (unlabeled, undated) containing used nail clippers, nail files, several bottles of nail used polishes and assorted used lotions. The Surveyor observed a patient owned motorized wheelchair scooter in the hallway of the second-floor patient care unit that was soiled, uncovered and belonged to a patient on Contact Precautions (procedures that reduce the risk of spread of infections through direct or indirect contact).

During the interview at 1:00 P.M. on 3/15/2022, the ACNO said the Hospital expectation was that any patient specific items would be cleaned when brought out of a patient care room and labeled with the patient's name and room number.

During the interview at 1:00 P.M. on 3/15/2022 the Hospital Infection Preventionist said the Hospital Infection Preventionists rounded in patient care areas, the Hospital's laboratory, and kitchen. The Infection Preventionist said they do not go to the Hospital's Outpatient Services Medical Group in Canton nor Brookline, and the staff at that site notified the Skilled Nursing Facility (non-Hospital facility) to speak to someone if they had questions about Infection Control. The Infection Preventionist said she collected Hospital Acquired Infection data, rounded on units and educated staff.

D.) Refer to TAG: 1077.

Based on observations, records reviewed and interviews the Hospital failed to ensure Outpatient Services were organized and integrated with Hebrew Rehabilitation Center (Hospital), Inpatient Services.

Findings Included:

The Surveyor observed, at 10:30 A.M. on 3/10/2022, when entering the Outpatient Clinic Reception area at Hebrew SeniorLife Medical Group at Orchard Cove, the Director of Nursing greeted the Surveyor said she was from the skilled nursing unit.

1.) Regarding Integration with Hospital Quality Assessment and Process Improvement Program:

During the interview, at 12:30 P.M. on 3/10/2022, Medical Director said the clinic((Hebrew SeniorLife Medical Group at Orchard Cove) did not participate in the Hospital's Quality Improvement.

2.) Regarding Integration with Hospital Patient Emergencies in Outpatient Services

The Hospital document titled Code Blue, dated 05/24/2021, indicated for this site, Orchard Cove, the staff would press the code blue button and call 9-911 from an outside line. The Code Blue policy indicated Code Blue equipment was stored on emergency carts in designated locations on each campus and assigned staff members should perform daily checks for the following items: Automatic External Defibrillator with pads, portable suction machine with suction tubing and yankauer (a plastic wand for mouth suctioning), backboard (a firm surface to place under a patient during CPR). Ambu-bag (manual resuscitation device for ventilating), a full oxygen tank, recorder clipboard with sheets and a pen.

The Surveyor observed, at 11:30AM. on 3/10/2022, in an upper locked cabinet, an auto-injecting Epinephrine (prescription medication given for life-threatening allergic reaction) medication pen called an Epi-pen. The Surveyor observed no other emergency equipment was identified.

During the interview at, 11:30 A.M. on 3/10/2022, RN #2 said the Epi-pen was in the cabinet for residents (patients) of the site (Orchard Cove, senior living community) that were having allergic reactions and would be administered to the patient by RN #2 depending on the patient's advanced directive. RN #2 said they called 911. RN #2 said she was not aware of the Hospital's Emergency or Code Blue Policies, the staff in the Skilled Nursing Unit (contained in the same building) did not respond to a Code Blue in the Medical Clinic (Hebrew SeniorLife Medical Group at Orchard Cove), and the Nurse and the Doctor or Nurse Practitioner from the Medical Clinic did not respond to the Skilled Nursing Units or the resident apartments for medical emergencies.

The Hospital policy titled Code Blue, dated 05/24/2021, indicated no indication that the Outpatient Satellite (Hebrew SeniorLife Medical Group at Orchard Cove) as an Outpatient Service of the Hospital was separate and distinct of Orchard Cove (the senior living community).

3.) Regarding Integration with Hospital Infection Prevention and Control and Antibiotic Stewardship Programs:

A.) The Surveyor observed, at 11:30 A.M. on 3/10/2022, in an area identified by RN #2 as the clean supply room. The Surveyor observed a refrigerator labeled "use for urines". The Surveyor observed no Hazard labels were identified on the refrigerator indicated for urine specimens. The Survey observed no refrigerator in the dirty supply room.

During the interview, at 11:30 A.M. on 3/10/2022, RN #2 said the dirty supply room did not have a refrigerator.

The Hospital provided to no corrective actions by the time of the Survey to relocate the urine samples (considered dirty) to a refrigerator in the dirty supply room.

B.) The Surveyor observed, at 11:45 A.M. on 3/10/2022, in a soiled utility room, supplies for the collection or urine (plastic cups with green caps, small tubes and transfer devices), a document titled Urinary Tract Infection Algorithm (undated, with indication as an official Hospital document). The Urinary Tract Infection Algorithm indicated treatment with antibiotics for a positive urinalysis test. The Urinary Tract Infection Algorithm indicated no documentation of integration with the Antibiotic Stewardship Program.

During the interview, at 2:00 P.M. on 3/8/2022, the Hospital Medical Director said the hospital had an ongoing Antibiotic Stewardship Program institution wide (Hospital wide).

The document titled Committee Charter, HRC Quality Assessment & Performance Improvement Committee, dated 2022, indicated no documentation of an Antibiotic Stewardship Program.

C.) During an observation, at 11:30AM., on 3/10/2022, of the Outpatient Services (at Hebrew SeniorLife Medical Group at Orchard Cove) the Surveyor observed a locked drawer in a patient exam room contained the following:

-a Dremel (hand-held rotary tool for home improvement or hobby use) with a soiled conical shaped grinding tip attached to it with no sterile wrapping on the instrument or the tip, the Dremel hard plastic case containing only a circular sandpaper-appearance packaged item that appeared unused, no additional shaped grinding tips were observed. The Surveyor observed the Dremel with a yellow-colored dust covered the entire surfaces and rotational parts of the Dremel. The Surveyor observed that the Dremel required being taken apart and cleaned.

-ten sterile packaged instruments, an unlabeled gray steel spray bottle with liquid contained in it, an opened, undated and partially filled bottle of thermostatic solution labeled Sluicing (a prescription solution used to control minor hemorrhage or bleeding), a box of steel surgical blades (scalpels), a box of chisel blades (a type of scalpel blade used by Podiatrists), and a blade handle (a surgical instrument used for holding the surgical blade).

During the interview, at 11:30AM. on 3/10/2022, the RN #2 said the supplies in the locked drawer belonged to a Podiatrist that visited one day a week. The RN #2 said the Podiatrist cut toenails and provided corn pads for the Patients during visits, however any more invasive procedures were done in the Podiatrist's office at a different location. The RN #2 said the Podiatrist was responsible for the instruments in the drawer, when the Podiatrist was done with the instruments, he placed them in a red bin on the exam room counter, the RN counted the instruments with the Podiatrist and the instruments were sent via courier to the Hospital or an undefined site for sterilization. RN #2 said the courier brought bins of clean (sterile) instruments to the clinic (Outpatient Service) from the Hospital or undefined sterilization site, and that RN #2 or the Clinic Coordinator put them in the Podiatry drawer.

4.) Regarding Integration with Hospital Pharmacy Services:

The Hospital document titled Hazardous and Non-Hazardous Medication: Safe Handling and Disposal, dated 10/25/2021, indicated any opened, unused or partially used medication must be disposed of in the black bucket waste container. Black buckets were located in medication rooms and soiled utility rooms. Nursing would notify Housekeeping when the Black Bucket was ¾ full for timely removal and replacement from the nursing floor/HH (undefined). Housekeeping would bring the black buckets to the CAA (Central Accumulation Area). Upon reaching the CAA all black buckets were dated with DOT (Department of Transportation) hazardous waste labels. The storage accumulation start date was to be entered on the DOT hazardous waste label at the time the waste arrived at the CAA and was picked up by authorized DOT transporter of hazardous waste within ninety days.

The Surveyor observed, at 11:30 A.M. on 3/10/2022, in an area identified by RN #2 as the clean supply room, a plastic basket on the counter labeled "expired medications" containing thee prescription bottles with various pills. The Surveyor observed no hazard labels were identified on the laundry basket containing medications.

During the interview, at 11:30 A.M., on 3/10/2022, RN #2 said patients brought expired or unwanted medications to the Wellness Center (Hebrew SeniorLife Medical Group at Orchard Cove), and the medications were placed in this basket. RN #2 said the medications in the basket were blood pressure medications. RN #2 said patients could bring narcotics to be disposed of in the expired medications basket but could not recall a different process of narcotic disposal. RN #2 said housekeeping services removed the medications from the basket when cleaning and disposed of them into a medication bin.

During the interview, at 12:00 P.M., on 3/10/2022, the Administrative Director of Medical Staff (at Hebrew SeniorLife Medical Group at Orchard Cove) said no medications were kept in the clinic and that no controlled substances were placed in the basket.

The Hospital provided to process that the Hospital Pharmacy Services were integrated with this Outpatient Service regarding medication disposal.

5.) Regarding Integration with Nursing Services:

During the interview at 3:00 P.M. on 3/10/2022, the Chief Nursing Officer said that Administrative Director (of the Medical Staff) was responsible for providing Outpatient Registered Nurses their performance evaluations; the Chief Nursing Officer said she did not know who was responsible for evaluating the Outpatient Registered Nurse's nursing practice (as the Administrative Director was not a nurse).

During the interview at 8:30 A.M. on 3/11/2022, the Associate Chief Nursing Officer said that she did not know if a nurse worked at the Brookline (the Outpatient Service, Hebrew SeniorLife Medical Group at Center Communities of Brookline).

6.) Regarding Integration with Hospital Laboratory Services:

The Surveyor observed, at 11:45 A.M., on 3/10/2022, the refrigerator temperature log was handwritten on a notepad; no official Hospital log documentation was identified.

Based on observations, records reviewed and interviews the Hospital failed to assign one or more individuals responsible for Outpatient Services, based on scope and complexity, necessary to direct the Outpatient Services for which they were responsible.

Findings included:

During the interview, at 11:30 A.M. on 3/10/2022, RN #2 said she formerly worked on the Skilled Nursing Unit (second floor at this building) and was asked by her Director of Nursing at the Skilled Nursing Unit to work in the Hospital Outpatient Service downstairs and RN #2 said yes. RN #2 said her direct supervisor was the Doctor (the Medical Director of Hebrew SeniorLife Medical Group at Orchard Cove, Outpatient Service). RN #2 said she was the only Nurse that worked in the Wellness Center (the Outpatient Service).

The Hospital provided no documentation to indicate evaluation of RN #2's Nursing competency or Nursing practice was integrated with or supervised by the Hospital's Nursing Service.

RN #2 said she was the only Nurse in the Wellness Center, and if she was out sick or on vacation, the Clinic (Outpatient Service) Coordinator covered the Nurse's assigned duties.
The Hospital provided no documentation (i.e., a policy) to indicate the Clinic Coordinator was qualified to coverage Nursing responsibilities. The Hospital provided no documentation to indicate the Outpatient Coordinator was a Registered Nurse.

A review of the Massachusetts Board of Registration in Nursing, dated 3/24/2022, indicated no RN license for the Outpatient Coordinator; indicating the Clinic Coordinator practiced Nursing without a Nursing license.

In an interview, at 12:30 P.M. on 3/10/2022, the Medical Director of Hebrew SeniorLife Medical Group at Orchard Cove, Outpatient Service said she completed a performance evaluation for the RN #2; however, she did not submit the performance evaluation or report the performance evaluation it to the Hospital Nursing Service . The Medical Director said she did not know who was responsible for the operation and oversight of the clinic (Hebrew SeniorLife Medical Group at Orchard Cove, Outpatient Service). The Medical Director said the room (Outpatient Service) was owned by the Independent Living Unit; however, the Administrative Director was responsible for Clinic Operations as well as the oversight of the Podiatrist. The Medical Director said the Podiatry service was there (Outpatient Service) per Orchard Cove's (senior living retirement community) request.

The Hospital Organizational Chart, dated ) indicated a Physician responsible for the Outpatient Service named Hebrew SeniorLife Medical Group at Orchard Cove as a Medical Director.

RN #2's Progress Summary (Performance Evaluation) indicated RN #2 a Physician proved RN's performance evaluation. which was inconsistent with RN #2's Job Description as a Registered Nurse to report to the Director of Nursing.