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Based on record review and interviews the Hospital failed to have independent written policies and procedures for patients requiring nursing and respiratory therapy care a during rapid response and cardio-pulmonary resuscitation at the Satellite Unit located in Natick because the nursing and respiratory care staff are personnel of the Host hospital.

Findings include:

Surveyor #1 and #2 interviewed the Nurse Manager of the Hospital's Satellite Unit at 7:45 A.M. during the tour of the Satellite Unit. The Nurse Manager said the Host Hospital rapid response teams (RRT) and the cardio-pulmonary (CPR) response team respond to the emergencies on the Unit. The Nurse Manager said the medical staff were credentialed physicians. The Nurse Manager said nursing and respiratory staff responding to the emergency were from the Host Hospital.

Surveyor #1 and #2 interviewed the Director of Quality and Risk at 10:00 A.M. on 6/17/13 and requested the Hospital Satellite Unit policies and procedures related to rapid response teams and cardio-pulmonary resuscitation.

The Hospital Satellite Unit policies and procedures related to rapid response teams and cardio-pulmonary resuscitation indicated the policies and procedures were not independent from the Host Hospital and titled with the Host Hospital's name.

Based on interview and observation, the Hospital failed to keep confidential the names of thirty-four in-patients of the Host-hospital.

Findings include:

Surveyor #1 and #2 observed at 8:15 A.M. on 6/13/13, two postings labeled LMH (Host-hospital) Daily Floor List. The LMH Daily Floor List indicated the names of 2 on-call physicians for the Hospital. However, there were 34 additional names printed on the schedule.

Surveyor #1 and #2 interviewed the Resource Chief Clinical Officer at 3:00 P.M. on 6/17/13. The Resource Chief Clinical Officer said the thirty-four names printed LMH Daily Floor List were the names of patients in the Host hospital.

Based on record review, the Hospital failed to identify that haldol (antipsychotic) was ordered and administered as a chemical restraint for one patient ( Patient #1) from a sample of ten patient records.

Findings include:

The Change of Condition Note, dated 4/19/12 at 6:49 A.M., indicates Patient #1 was assessed as confused, disoriented and hallucinating.

Physician Progress Notes, dated 4/19/12 at 2:15 A.M., indicated Patient #1 was examined for respiratory distress and assessed as anxious.

The Medication Administration Record, dated 4/19/12, indicated at 2:45 A.M. Patient #1 received haldol 1 milligram (mg) intra-muscularly for increased agitation.

According to the medication (haldol) manufacturer, the indication for use of this anti-psychotic are Schizophrenia and Tourette's disorder.

Based on review of documentation and staff interview, the Hospital failed to prohibit the use of p.r.n. (an abbreviation for as needed) orders for use of a chemical restraint for one patient ( Patient #9) from a sample of ten patients records.

Findings include:

Physician Orders for Patient #9, dated 5/20/13, indicated haldol 1 milligram (mg) intra-venous (IV) was ordered to be administered every 2 hours p.r.n. for severe agitation.

Physician Orders for Patient #9, dated 6/8/13, indicated haldol 5 milligram (mg) intra-muscular (IM) was ordered to be administered every 8 hours p.r.n. for severe agitation.

Physician Orders for Patient #9, dated 6/11/13, indicated haldol 5 milligram (mg) intra-muscular (IM) was ordered to be administered every 6 hours p.r.n. for moderate agitation mild anxiety.

Based on interviews and record review, the Hospital failed to ensure that all entries in one (Patient #1) of ten medical records were accurate.

Findings include:

The Social Workers progress note, dated 4/12/12 at 10:10 A.M., indicated Patient #1's Attending Physician was present at a family meeting on 4/10/12.

Surveyor #1 and #2 interviewed the Attending Physician of Patient #1 at 11:15 A.M. on 6/13/13. The Attending Physician said the medical record entry including her in the family meeting held on 4/10/12 was incorrect.

Surveyor #1 interviewed Patient #1's Social Worker (SW) at 2:30 P.M. on 6/17/13. The SW said she did not remember the family meeting. The SW said at the time she wrote her note, the electronic data screen prompted her to enter the physician's name. The SW said in order to correctly identify attendees at family meetings she now enters data in a different and more accurate way.

The Physician Progress Note, dictated on 4/7/12 at 1:30 P.M., indicated a covering physician entered an incorrect date of service as 2/7/12 into Patient #1's medical record instead of the actual date of 4/7/12.