DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION		 (X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER		 (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED
220002 A. BUILDING __________
B. WING ______________ 		10/30/2023
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP
MOUNT AUBURN HOSPITAL 330 MOUNT AUBURN STREET, CAMBRIDGE, MA, 02138
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See reverse for further instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation
LABORATORY DIRECTOR’S OR PROVIDER/SUPPLIER REPRESENTATIVE’S SIGNATURE

 TITLE

 (X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
(X4) ID
PREFIX
TAG		 SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY SHOULD BE PRECEDED BY FULL
REGULATORY OR LSC IDENTIFYING INFORMATION)
A0115 Patient Rights
482.13
Corrected On: 02/01/2024
45980 The Hospital was out of compliance for the Condition of Participation for Patient Rights. Findings included: The Hospital failed to ensure for one (Patient #4) of 10 sampled patients that the Hospital provided care in a safe setting. Refer to Tag: A-0144.
A0144 Patient Rights: Care In Safe Setting
482.13(c)(2)
Corrected On: 02/01/2024
45980 Based on interviews and records reviewed, the Hospital failed to provide care in a safe setting for one (Patient #4) of 10 sampled patients, when Patient #4 was able to extricate him/herself from three of four limb restraints applied while on 1:1 constant observation resulting in injury. Findings include: Review of the Hospital's Care of the Patient at Risk for Harm to Self or Others Policy, dated October 2021, indicated that Nursing Administration/Nursing Supervisor would be notified of all at risk patients and would assign constant observation workers to patients each shift. The Policy indicated an observation worker or protection service personnel/security officer would be assigned to only one patient (1:1 observation) at a time and notify nursing in the event a patient attempted any dangerous behaviors, document an observation log, and follow the patient during testing or transport. Review of the Hospital's Use of Restraints Policy, revised on 4/12/23, indicated that an order must be obtained from a physician or physician assistant who was directly supervised by a physician and was responsible for the care of the patient during or immediately after the restraint application. The order was time-limited as follows: a. four hours for adults 18 and older. Review of the medical records indicated Patient #4 was brought to the Emergency Department (ED) by the Fire/Police Department after being placed on a Section 12 (Emergency restraint and temporary involuntary hospitalization of a person posing risk of serious harm by reason of mental illness) after he/she destroyed property and displayed manic behaviors in the community. Review of the Hospital's Safety/Security Event Report, dated 7/31/23, documented by the Attending Physician, indicated that at approximately 11:30 A.M., Patient #4 was chemically and physically restrained and assigned 1:1 observation due to safety concerns, had managed to extricate him/herself from all four-point restraints, and then got into a physical altercation with [security] staff. The Report indicated that during the re-restraint application, a security officer received multiple strikes/blows [from Patient #4] and in defense, the security officer allegedly struck Patient #4 in the face with a single blow. Review of Patient #4's medical record indicated that there was no written physician order for the physical restraint applied to Patient #4 at approximately 11:30 A.M on 7/31/23. Review of the Department of Public Health's Health Care Facility Reporting System, dated 8/4/23, indicated that Patient #4 was brought to the ED under Section 12 due to alcohol intoxication and agitation. The Report indicated that on 7/31/23, at approximately 11:30 A.M., Patient #4 attempted to elope from the ED and became verbally and physically aggressive with staff, resulting in security officers placing Patient #4 in four-point physical restraints and assigning a contracted security officer to provide constant 1:1 observation. The Report indicated that approximately 10 to 20 minutes later, Patient #4 extricated him/herself from three of the four restraints and continued to display aggressive behaviors towards others, requiring the contracted security officer and another security officer to re-apply the physical restraints, and additional chemical restraint medications were administered. The Report indicated that during the restraint application encounter, Patient #4 sustained bilateral comminuted nasal bone fractures and a fracture of the anterior maxillary spine; additionally, the security officer sustained a laceration on the right middle finger and minor bruising and sprain of the right hand. The Report indicated the Hospital's Investigation determined the injuries sustained during Patient #4's restraint application were likely preventable. Review of the Hospital's internal Investigation included the Root Cause Analysis (RCA), dated 8/10/23, which indicated that there were inadequate staffing ratios to meet patient safety needs on 7/31/23, when the staff member assigned to provide 1:1 observation for Patient #4 was providing safety observation for two patients at the time of the event, which was not in accordance with Hospital Policy. The RCA indicated Patient #4's restraints were applied in suboptimal conditions in the hallway. The RCA indicated there was no standardized training for restraint application or standardized training for de-escalation techniques for staff. Further review of the Hospital's internal investigation/RCA indicated there was no documentation to support the Hospital implemented and monitored systemwide education/training in response to Patient #4's restraint event on 7/31/23. During an interview on 10/26/23 at 9:22 A.M., the Manager of Protection Services said he manages the security officers, who are trained to apply physical restraints and on de-escalation techniques and the contracted security officers are trained to provide constant 1:1 observation, de-escalation techniques, and to assist trained security officers during a physical restraint application. The Manager said he participated in the RCA involving Patient #4 and staff injuries sustained during a restraint application on 7/31/23; however, the Manager said there was no documentation to support the contracted/security staff members were re-educated on standardized competency process for restraint application or de-escalation training as indicated in the RCA. During an interview on 10/26/23 at 11:50 A.M., the Contacted Security Officer indicated that on 7/31/23, he was assigned to provide 1:1 observation of Patient #4 due to his/her violent behaviors directed towards others. The Officer acknowledged that as the 1:1 observer, it was required to provide constant safety observations, on or off the unit, for the assigned patient. The Officer indicated that a staff member who worked in imaging, came to the ED to transport Patient #4 off the unit to a computerized tomography (CT) scan; however, he said he asked the staff member to wait to take Patient #4 off the unit because he did not want to leave the ED as there was not enough security/observation workers at that time. The Officer said the staff member did not listen to him and transported Patient #4 from the ED to the CT scan anyway. The Officer said he did not notify Patient #4's assigned nurse (later identified as Registered Nurse #1) once Patient #4 was taken off the unit by another staff member without a 1:1 observer/security staff. The Officer said he would not do anything differently on 7/31/23, such as continuing the 1:1 observation for Patient #4 during the CT scan or notifying Registered Nurse #1 that he did not accompany Patient #4 to CT scan. During an interview on 10/30/23 at 11:12 A.M., Registered Nurse (RN) #1 indicated that although she removed Patient #4's physical restraints in the ED prior to the CT scan, she was unaware the 1:1 observer (later identified as Contracted Security Officer) did not follow Patient #4 to the scan. Registered Nurse #1 said it was required that the staff member assigned to provide 1:1 observation accompany Patient #4 off the unit to continue monitoring for unsafe behavior. During an interview with the Director of Quality and Safety and the Director of Regulatory Affairs and Performance Improvement on 10/26/23 at 12:40 P.M., they acknowledged there was no documentation to support the contracted/security staff members were re-educated on standardize competency process for restraint application or de-escalation training in response to Patient #4's event on 7/31/23. The Director of Quality and Safety and the Director of Regulatory Affairs and Performance Improvement acknowledged the Investigation did not identify that the Contracted Security Officer did not notify Registered Nurse #1 and/or accompany Patent #4 during the CT scan and transport; additionally, the Investigation did not identify that there was no written physician order for the physical restraint applied to Patient #4 at approximately 11:30 A.M on 7/31/23.
A0263 QAPI
482.21
Corrected On: 02/01/2024
45980 The Condition of Participation of Quality Assessment & Performance Improvement Program was not met. Findings included: The Hospital failed to implement corrective actions to prevent a like occurrence from happening for one (Patient #4) of 10 patient records reviewed. Refer to Tag: A-0286.
A0286 Patient Safety
482.21(a), (c)(2), (e)(3)
Corrected On: 02/01/2024
45980 Based on interviews and record reviews, the Hospital failed for one patient (Patient #4) out of a sample of 10 patients, to provide system wide implementation of preventative actions after Patient #4 was able to extricate him/herself from 3 out of the 4 limb restraints applied while on 1:1 constant observation. Findings include: Review of the medical records indicated Patient #4 was brought to the Emergency Department (ED) by the Fire/Police Department after being placed on a Section 12 (Emergency restraint and temporary involuntary hospitalization of a person posing risk of serious harm by reason of mental illness) after he/she destroyed property and displayed manic behaviors in the community. Review of the Hospital's Care of the Patient at Risk for Harm to Self or Others Policy, dated October 2021, indicated that Nursing Administration/Nursing Supervisor would be notified of all at risk patients and would assign constant observation workers to patients each shift. The Policy indicated an observation worker or protection service personnel/security officer would be assigned to only one patient (1:1 observation) at a time and notify nursing in the event a patient attempted any dangerous behaviors, document an observation log, and follow the patient during testing or transport. Review of the Hospital's Use of Restraints Policy, revised on 4/12/23, indicated that an order must be obtained from a physician or physician assistant who was directly supervised by a physician and was responsible for the care of the patient during or immediately after the restraint application. The order was time-limited as follows: a. four hours for adults 18 and older. Review of the Progress Note documented by the Attending Physician, dated 7/31/23 at 11:30 A.M., indicated that Patient #4 attempted to elope, was agitated and aggressive with verbal escalation. He noted Patient #4 was threatening physical and bodily harm and that Patient #4 required four-point restraint with subsequent chemical sedation. Review of the Hospital's Safety/Security Event Report, dated 7/31/23, documented by the Attending Physician, indicated that at approximately 11:30 A.M., Patient #4 was chemically and physically restrained and assigned 1:1 observation due to violent safety concerns, had managed to extricate him/herself from all four-point restraints, and then got into a physical altercation with [security] staff. The Report indicated that during the re-restraint application, a security officer received multiple strikes/blows [from Patient #4] and in defense, the security officer allegedly struck Patient #4 in the face with a single blow. Review of Patient #4's medical record indicated that there was no written physician order for the physical restraint applied to Patient #4 at approximately 11:30 A.M on 7/31/23. Review of the Department of Public Health ' s Health Care Facility Reporting System, dated 8/4/23, indicated that Patient #4 was brought to the ED under Section 12 due to alcohol intoxication and agitation. The Report indicated that on 7/31/23, at approximately 11:30 A.M., Patient #4 attempted to elope from the ED and became verbally and physically aggressive with staff, resulting in security officers placing Patient #4 in four-point physical restraints and assigning a contracted security officer to provide constant 1:1 observation. The Report indicated that approximately 10 to 20 minutes later, Patient #4 extricated him/herself from three of the four restraints and continued to display aggressive behaviors towards others, requiring the contracted security officer and another security officer to re-apply the physical restraints, and additional chemical restraint medications were administered. The Report indicated that during the restraint application encounter, Patient #4 sustained bilateral comminuted nasal bone fractures and a fracture of the anterior maxillary spine; additionally, the security officer sustained a laceration on the right middle finger and minor bruising and sprain of the right hand. The Report indicated the Hospital ' s Investigation determined the injuries sustained during Patient #4 ' s restraint application were likely preventable. Review of the Hospital's internal Investigation included the Root Cause Analysis (RCA), dated 8/10/23, which indicated that there were inadequate staffing ratios to meet patient safety needs on 7/31/23, when the staff member assigned to provide 1:1 observation for Patient #4 was in fact providing safety observation for two patients at the time of the event, which was not in accordance with Hospital Policy. The RCA indicated Patient #4 ' s restraints were applied in suboptimal conditions in the hallway. The RCA indicated there was no standardized training for restraint application or standardized training for de-escalation techniques for staff. Further review of the Hospital's internal investigation/RCA indicated there was no documentation to support the Hospital implemented and monitored systemwide education/training in response to Patient #4 ' s restraint event on 7/31/23. During an interview on 10/26/23 at 9:22 A.M., the Manager of Protection Services said he manages the security officers, who are trained to apply physical restraints and on de-escalation techniques and the contracted security officers are trained to provide constant 1:1 observation, de-escalation techniques, and to assist trained security officers during a physical restraint application. The Manager said he participated in the RCA involving Patient #4 and staff injuries sustained during a restraint application on 7/31/23; however, the Manager said there was no documentation to support the contracted/security staff members were re-educated on standardize competency process for restraint application or de-escalation training as indicated in the RCA. During an interview on 10/26/23 at 11:50 A.M., the Contacted Security Officer indicated that on 7/31/23, he was assigned to provide 1:1 observation of Patient #4 due to his/her violent behaviors directed towards others. The Officer acknowledged that as the 1:1 observer, it was required to provide constant safety observations, on or off the unit, for the assigned patient. The Officer indicated that a staff member who worked in imaging, came to the ED to transport Patient #4 off the unit to a computerized tomography (CT) scan; however, he said he asked the staff member to wait to take Patient #4 off the unit because he did not want to leave the ED as there was not enough security/observation workers at that time. The Officer said the staff member did not listen to him and transported Patient #4 from the ED to the CT scan anyway. The Officer said he did not notify Patient #4's assigned nurse (later identified as Registered Nurse #1) once Patient #4 was taken off the unit by another staff member without a 1:1 observer/security staff. The Officer said he would not do anything differently on 7/31/23, such as continuing the 1:1 observation for Patient #4 during the CT scan or notifying Registered Nurse #1 that he did not accompany Patient #4 to CT scan. During an interview on 10/30/23 at 11:12 A.M., Registered Nurse (RN) #1 indicated that although she removed Patient #4 's physical restraints in the ED prior to the CT scan, she was unaware the 1:1 observer (later identified as Contracted Security Officer) did not follow Patient #4 to the scan. Registered Nurse #1 said it was required that the staff member assigned to provide 1:1 observation accompany Patient #4 off the unit to continue monitoring for unsafe behavior. During an interview with the Director of Quality and Safety and the Director of Regulatory Affairs and Performance Improvement on 10/26/23 at 12:40 P.M., they acknowledged there was no documentation to support the contracted/security staff members were re-educated on standardize competency process for restraint application or de-escalation training in response to Patient #4 ' s event on 7/31/23. The Director of Quality and Safety and the Director of Regulatory Affairs and Performance Improvement acknowledged the Investigation did not identify that Contracted Security Officer did not notify Registered Nurse #1 and/or accompany Patent #4 during the CT scan and transport; additionally, the Investigation did not identify that there was no written physician order for the physical restraint applied to Patient #4 at approximately 11:30 A.M on 7/31/23.