BRIGHAM AND
HOSPITAL

 

March 10,2015

Ms. Jane Comerford

Hospital Complaint Unit Manager
Department of Public Health

Division of Health Care Quality, (DHCQ)
99 Chauncy Street, 11th Floor

Boston, MA 02111

Re: Reference 14-1181
Dear Ms. Comerford:

Enclosed please ?nd the Brigham and Women?s Hospital Plan of Correction to the above
referenced survey and State of De?ciencies recently received by this of?ce on February
26, 2015.

If you have any questions or concerns, please do not hesitate to call.

Very Truly Yours,

Mk

David E. Seaver

Risk Manager

Brigham and Women?s Hospital
75 Francis Street

Boston, MA 02115

75 Francis Street Boston, Massachusetts 02115


 

 A Teaching Affiliate of 
Hi ude' 151 1 
"r 8 'Ca 100 Member of  - Healthare

62/24/2615 81: 16

6172646366

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE 8c MEDICAID SERVICES

 

STATQMENT OF DEFICIENDIES
AND PLAN OF CORRECTION

PAGE 89/23

PRINTED: 02/13/2015

FORM APPROVED

OMB NO. 0938?0391

 

 

1X1) 
IDENTIFICATION NUMBER:

220110

 

 

IX2) MULTIPLE CONSTRUCTION

A. BUILDING

B. WING

 

 

 

(X3) DATE SURVEY
COMPLETED




 

NAME OF PROVIDER 0R SUPPLIER
BRIG HAM AND HOSPITAL

 

STREET ADDRESS. CITY. STATE. ZIP CODE
75 FRANCIS STREET
BOSTON. MA 02115

 

(X4) ID
PREFIX
mo

SUMMARY STATEMENT OF DEFICIENCIES
(EACH DEFICIENCY MUST BE PREGEDED BY FULL 
REGULATORY OR I.SC IDENTIFYING INFORMATION) 

ID
PREFIX
TAG

PLAN OF CORRECTION
(EACH CORRECTIVE ACTION SHOULD

CROSS-REFERENCED TO THE APPROPRIATE

DEFICIENCY)


COMPLETION
DATE

BE

 

A 000

A131

 

 

INITIAL COMMENTS

A CMS authorized substantial ailegation survey
was conducted (ACTS Reference Number
MA00022806) On 1/8. 1/12. 1/13, 1/14. 1/15 and
1/20/15 at:

Brigham and Women's Hospital
75 Francis Street
BostonI MA 02115

The following Conditions of Participation were
reviewed using a sample of 10 patients.

482.12 Governing Body

462.13 Patient Rights

482.22 Medical Staff

482.23 Nursing Services

432.25 Pharmaceutical Services

 

462.42 infection Control
PATIENT RIGHTS: INFORMED
CONSENT

The patient or his or her representative (as
allowed under State law) has the right to make
informed decisions regarding his or her care.

The patients rights. Include being informed of his
or her health status, being involved in care
planning and treatment. and being able to request
or. refuse treatment. This right must not be
construed as a mechanism to demand the
provision of treatment or services deemed
medically unnecessary or inappropriate.

This STANDARD is not met as evidenced by:
Based on records reviewed. and staff interview.
the Hospital failed to ensure an authorized
representative, as allowed by State law. signed

 

A 000

A131

 

i

I

Health Care Proxy Activation

The Medical intensive Care Unit medical staff
were reminded on 03/02/2015 to write a note
in the medical record when the patient is
deemed to be unable to make his/her own
medical decisions and invoke the authority of

the patient?s healthcare proxy.

 

 

 

Any da?oisndy statement ending with an asterisk 
other safeguards provide suf?cient protection to th
following the bats of survay whether or not a plan

days lollowin

i

REPRESENTATIVES SIGN 

monogamous 

program part dipsticn.

skmg,?

'l denotes a de?otency which the institutlon may be excused (?lm correcting providing it is determined that
a patients. (See instructions.) Except for nursing homes. the ?ndings stated above are disclose

I of correction is provided. For nursing homes, the above ?ndtn
the data these documents ate made avallabte to the facility. If de?ciencies are cited. an approvag

TITLE

9 and plans of correctlo

plan of correction Is requisite to 

5/167}, 

bIe 90 days
Iosable 14
ontinued

are cited

 

 

FORM Previous Versions Obsolete

'r

 

Event ID: 0T5Z11

Facility ID: 23:11

if continuation sheet

Page tof155

 

82/24/2815 81:16 6172646365

OF HEALTH AND HUMAN SERVICES
cEN'rEiaa FOR MEDICARE MEDICAID SERVICES

PAGE 18/23

PRINTED 02/13/2015;

FORM 

OMB no 0938-03in

 

 

 

 

 

 

 

 

 

 

informed consent for Invasive procedures in two
of two incapacitated patients (Patient #6 and 
in a total sample often patients. The Health Care
Proxy was not activated by the attending
physician in the medical record as required by
Hoepsitl policies and Procedures.

Findings inctude:

The Hospital policy titled Health Care Proxies and
Living Wills, dated August 2013. indicated the
attending physician makes the determination that
apatient lacks the capacity to make healthcare
decisions. The attending physician must
document the determination of incapacity and the
surrogate decision maker in the patient's medical 
record. 

 

i

The medical record for Patient #6 indicated i
heishe had respiratory failure, was ventilator
dependent and sedated. Informed consent forms 
for Patient #6 indicated the Health Care Proxy
signed the informed consents for bronchoscopy
(a medical test to view the airways and lungs) and
the placement of an arterial line (a thin catheter
inserted into an artery.) The medical record did
not indicate the Health Care Proxy was activated
byi'the attending physician as required by Hospital
po icy.

The medical record for Patient #7 indicated
hie/she had dementia. The informed consent form
for Patient #7 indicated the Health Care Proxy
signed the informed consent for a lracheostomy
(a surgical procedure to create an opening
through the neck.) Review of Patient #T's
informed consent form indicated Patient #7'5
Health Care Proxy signed the informed consent
for the tracheoslomy procedure. The medical

 

 

 

 

i
i
I

STATEMEN on DEFICIENCIES no) PROWDERISUPPLIERICLIA 9(2) MULTIPLE consrsuc'non no) DA sunvev
AND PLAN connecnon IDENTIFICATION A BUFLDI co PLETED
. NG
i
220110 e. WING onizorgpi 5
NAME OF fineness on eraser ADDRESS. STATE. ZIP cone
75 FRANCIS STREET
Ans OSPITA
-. A. BOSTON, MA 02115
In I SUMMARY STATEMENT or lD PROVIDER-s PLAN 05 coasecnon pie)
. (EACH DEFICIENCY MUST BE PRECEDED sv FULL PREFIX (EACH connecnvs ACTION secure as .COMPLETION
TAG REGULATORY OR LSC TAG To THE APPROPREATE DATE
DEFICIENCY)
A 131 Continued From page i A 131

 

FORM ems-ate7r?t-ss) Previous Versions Obsolete Event iD: 

I


 

Facility tD: 2341

if continuation sheet

 

Page 2 of15g

 

 

82/24/2815 81:16 6172546355 PAGE 11/23.

 
     
 

 

 

  

 

 

 

 

 

 

 

 

 

 

I
DEPAR OF HEALTH AND HUMAN SERVICES 
CENT MEDICARE 81 MEDICAID SERVICES OMB NO
x1 
AND PLAN donnECTIoN IDENTIFICATION NUMBER: ?gxf?za CONSTRUCTION I
I  
I
A 3. 220110 B. WING . 01I2012015 I
NAME oxowosn on SUPPLIER STREETADDRESS. CITY. STATE. ZIP CODE 
anteH Atop HOSPITAL 75 ?was STREET
1. MA 92115
out) to i SUMMARY STATEMENT or DEFEGIENCIES In Pnovroan's PLAN on CORRECTION 1st i
FREFIX I (EACH DEFICIENCY MusT BE av FULL 5 
TAG I REGULATORY on IDENTIFYING INFORMATION) Whig? oomg?gm 
DEFICIENCY131 continued From page 2 A131
Iton did not Indicate the Heatth Care Proxy was
aftIVatsd by the attending physician as required
b4 Hospital policy.
T. $urveyor interviewed the Medical Director of
. 'lt?ledlcal Intensive Care Unit (MICU) at 1:00
. on 1/14/15. The Medical Director oI the
said that the Attending Physician Is
I .uired to enter a note into the Progress Notes I
7 a Health Care Proxy Is activated. i .
A 347 4 [22(bm)? (3) MEDICAL STAFF A 347 Hospital GUIdeItne for Preventlon of
GANIZATION ACCOUNTABILITY Intravascular Catheter Related Infection
BWH's ?Guidelines for Prevention of
medical staff must be well organized and Intravascular Catheter-related Infections" is
a' bountable to the governing body for the quality available on the awn Infection Control

 

medical care provided to the patients. Department intranet website and is based
I on 2011 recommendations.

The medical staff must be organized In a 
I

nher approved by the governing body.

After review of the current policy, the
guideline was amended to note that clinical

 

i.

- . I judgment is needed to weigh the potential.
 
cdmmittee must be doctom of medicine or speCIfIc patlent situations. We have reVIsed
ogreopathyi the wordIng of this gu:delme to better reflect

this. The updated guideline was approved
(ib  responsibil?y for organization and by the Infection Control Department on
tiiduct of the medical staff must be assigned 3/4/2015- On 3/9/15. the Infection Control I
of? in one of the following: posted the updated guideline on the

?1  An Individual of medicine or Infection Control Website on and shared
0 iegpathY- this with patient #4 unit's Nursing Director.

1 dOCtor 0f denfal surgery or dental The Infection Control Inpatient

meme' when permt?ed by State 'aw 0f the Environmental Rounds Monitoring tool has

8 t? In which the hospital Is located. - .
A doctor of podiatric medicine, when been Updated to re?w education'

 mmed by Slate law of the State in which the observation and documentation.

edital is located.

 

 

 

 

 

FORM lined) Previous Versions Obsolete Event ID: 0T521t Facility ID: 2341 If continuation shoe?Page 3 of 15 i

 

 

 

 

 

 

62/24/2815 81:16 6172646366 PAGE 12/23

02M 3/201

 

  
 

 

 

 

 

 

 

 

 

 

 

NT OF HEALTH AND HUMAN SERVICES FOR APPROVEU
CENTER Iron MEDICARE a SERVICES 0 a N0 0930-0391
STATEMEN 0 XI) PROVIDERISUPPLIERJCIJA X2 MULTIPLE CONSTRUCTION xa DATE 5 
AND PLAN or: I NUMBER: ?1 ?1?me 
t:
I . 220110 a. WING 0110012015
NAME OF PREEWER on sunnuen STREET ADDRESS. CITY. STATE. coca
.- 75 STREET
BRIGH . I in women's HOSPITAL
g) BOSTON, MA. 02115
iD SUMMARY STATEMENT OF In I PLAN OF CORRECTION 
(EACH DEFICIENCY MUST BE PREOEDED BY FULL (EACH CORRECTNE ACTION SHOULD BE COMPLETION
TAG REGUWORY 0R LSC TAG CROSS-REFERENCE TO THE APPROPRIATE ME
I DEFICIENCY)
all For awareness and sustainability of this
A 347 ?nF?nued From page a A 347 education, the section wiil be reviewed
SISTANDARD ?3 net met 35" eVldenced by: annually during infection Control rounds with

  
 
    
    
     
 
  
 
   
 
     
 
 
 
 
  
  

on record review and intewiew, the patient #4 unit Nursing staff and a report of

spite! failed to ensure that the Medical Staff compliance Wm be provided to the patient #4

I red to the Hospital's Guidelines for the .t D. 

reiniion of lntravascuiar Catheter Related Um wise 'rec 0" 

tions for one of ten sampled patients (Patient me Assessment and Dressmg Change
The Pavilion nursing staff will have PICC Line

care included in their annual competency

Fittings inciude: training.

 

. he Hospital's infection Control Policy titted
idolines for Prevention of inbavascular

meter Related Infections. approved 10/12/11.
lc'ated that a Perlpherally Inserted Central
tHeter (a is an intravenous access that
it be used for a prolonged period of time) was
beirsrnoved if there was clinical evidence of a
.thi?ter infection.

Nurses Notes dated. 10/7/14 at 5:00 AM,
idated Patient #4 experienced rigors (a sudden
eiitig of cold with shivering) and malaise (a
diticn of genera: bodily weakness).

interdisciplinary Progress Note; dated

7?14 and signed by Patient #4's Attending
stician, Indicated Patient #4 had an increase in
I ta blood coils (War: a) from 7000 to 11,000
primal is 4500 to 10.000; an increase may
?io'ate infection) and reported chills. The

egding Physician Note indicated a concern for
line infection and that the PICC line Would
eiy'need to come out.

 

Physician Orders, at 8:15 AM. on 10/7/14.
.icetsd (an antibiotic) 1000

illd?rams (mg) to be administered every twelve
013(in duration indicated in the order) for
dirt The medication administration record

FORM OMS-2E shit 595%) Previous Versions Obsolete Event iDIO?r5Zii Facility ID: 2341 If continuation shes Page 4 of 15

i .

 

 

 

 

 

 

 

 

 

 

 

82/24/2815 61:16 6172646366 I PAGE 13/23

 

 

 

 

 

 

 

 

newer ?an OF HEALTH AND HUMAN SERVICES PR?dggii ??i??iWS
centre MEDICAQSERVICES OMB no 09380391
(X1) PROVEDERISUPPLIEWCLIA  MULTIPLE. CONSTRUCTION (X3)  SURVEY
AND PLAN IDENTIFICATION NUMBER: A. CON PLETED
229110 B. Mi?oizmo
NAME OF OR STREET ADDRESS. CITY. STATE. ZIP CODE

75 FRANCIS STREET
BOSTON. MA 02135

 

BRIGHA  women's HOSPITAL


 

K4) in . summnv STATEMENT OF oencenctse io PLAN or CORRECTEON (K5)
nest): MUST BE PRECEDED ev FULL PREFIX (EACH CORRECTNE SHOULD BE . COMPLETION
TAG RIEGULATORY 0R L80 TAG onoes-nenenenoeo ro we APPROPRIATE DATE
DEFICIENCY)


 

 

 

:nlinued From page 4 A 347
i tied 1000 mg was administered

etientirzi beginning at 8:48 AM. on 10/7/14.
1L @hyeloien Progress Note. dated 10/8/14 at
?20 .10., indicated Palient#4 had a temperature
 .8 degrees Fahrenheit (normal is 97.8 to 99

A 347

{2 

 

1:100)

donned) and had a low blood pressure.

gurveyor interviewed Hospital Physician #1
:50 AM. on 1/20/15. Hospital Physician #1 i
., faiientws PICC line was not discontinued. 
. ital Physician #1 said he believed there was ,2 i
din discussion about asking for an infectious . 
ebee consult, but Hospital Physician #1 did not; 
.i .9 this happened. Hospital Physician #1 said
 ed decided that Patient #4'3 of
- dllion were related to the series of injections

file/her knees.

 

   
   
  
  
 
   
  
   

 

?i din #4?5 medical record entries from 10/7/14
align 10/25/14 did not indicate the knee
2 "one as a possible cause for the 
Willa. malaise. fever or increase in W80

1

FE '.eeouler Catheter Related infections, a
item with a PICC line and clinical signs of
549- rigors. malaise. temperature and
Voted would require careful
 jel?ement of the insertion site for erytherna
111,588). induretion (swelling) or purulenoe

lit flaneperent dressing were to be changed 
 T'days or when the dressing became
eehed or soiledPICC line dressmg 
FORM OMS-atoll  Previous Versions Dbaolete Event 10:01'6211 Fadiini $12341 if continuation 5 of 15 i

 

 

 

gametes Notes, dated 10/8/14. indicated
5

I.

ll
..
i

i-i'

 

 

 

 

 

62/24/2615 61:16

6172646366

PAGE 14/ 23

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

  
      
  
 
  
   
 

 

 

 

 

 

 

 

 

 

 

 

 

cement/gut or: HEALTH AND HUMAN 102? 13? 2?15
Sifgg?fd l?ilgiilSCARE (it; OMB Mi; 99138-0391
y. 1) X2 MULT 
AND PLAN or: die?mention IDENTIFICATION NUMBER: L. gummy; CONSTRUCTION ?3?83 31%?
.. i . 220110 9- WM 01 012015
NAME OF meridian-?on srneer CITY. STATE, ZIP cons 
women's 75 FRANCE STREET 
i .4. aosron. MA 02115 
pm, to SUMMARY STATEMENT OF in PLAN orc ns 
max I (EACH MUST BE PRECEDED av FULL PREFIX connecrive as con?gnow
TAG .1 REGULATORY 0R Lee IDENTIFYING INFORMATION) TAG CROSS-REFERENCED To THE APPROPRIATE DATE 
i DEFICIENCY)
A 347. tinned From page 5 A 347
nge. The Nurses Notes indicated. Patientiitti
the dressing change and no evidence
hiin'eeition site assessment was present in -
leht-4's medical record through 10/25/14. i
'thysician Orders, dated 10/7/14 at 6:15
 indicated Patient #4'5 PICC line dressing
to be changed by Registered Nurse #7 and
7' ok to go longer than seven days.? This
 eohtradlctory to the catheter dressing
n, policy and accepted standards of care.
urveyor interviewed Registered Nurse #7 at
. .M. on 1/14/15. Registered Nurse #7 was
in the Physician Order dated 10/8/14 as 
tgg?iegistered Nurse that Patientit?ii would allow
t. l'Ehange hie/her PICC line dressing. Registered .
Ni 'se #7 said Pattenti?M was ?xated on 
ething happening to the P100 line and would i
. re?ilow just any Registered Nurse to change the 
3 ing. 
A405 4- (0X2) ADMINISTRATION I A405 Sad-Administered Medications
. to The Private Duty Nurse Policy was updated
bl I - on 3/4/15 to ensure all staff understands the 
(-  98 an . ogicals mus? be prepared and role of the private duty nurse. Speci?cally, the
a . II ?ared In accordance w'm Federal and amended policy states that "care is limited to
. tailaws. the orders of the practitioner ?ctitloners responsible for the patients care as the ?0?43? 9f aCt'V't'eS of da'ly wager?: 
3. . Urged under ?8212(0). and accepted companionship measures only. At all times 1
3' ?(jaws of practice. there wiil be a Brigham and Women's Hospitai
 .5 Registered Nurse assigned responsibility for
 hugs and biologicals may be prepared and the care of the patient." Private Duty Nurses
3 gm Istered on the orders of other practitioners wiil not be permitted to administer medications
It specified under only if to patients. This includes orai medications and
qw?monem are acung accordance With Siam intravenous medications.
is .. lhcludlng scope of practice laws. hospital i
 tales. and medical staff bylaws. ruiee, and 
re stations.
9 ii.  
Fonlvl OMS-26 67.3! 551%? Previous Versions Obsolete Event ID: 075211 Faculty it): 2341 If continuation sha?iPege 32/24/2815 81:16

  

5172646366

PAGE .15/23 I

 

 

 

 

 

 

 

     

 

 

 

 

 

 

 
   
     
 
      
   
    

 

 

 
   
  
 

 

 

 

 

 0313;2015' 

 

I i
.. Nil" OF HEALTH AND HUMAN ssnwoss .
..  . . PPROVED
..  .. . MEDICAID SERVICES OMB 0933 
STAT t. 
 testers screenings  ?its
3' - ?2
35.4 220110 a.unNo 
NAME or stationed on SUPPLIER STREET ADDRESS. oIrv. srn?rc. cops 
. . . 75 STREET
BRIGHAM  WOMEN HOSPITAL MA 02115
(X4) ID  SUMMARY STATEMENT OF DEFICIENCIES I0 PROVIDERS PLAN or (X5) I
1 CH DEFICIENCY MUST BE PRECEDEE) BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD DE . 
TAG i REGULATORY on TAG T0 THEAPPROPRMTE DATE
i A DEFICIENCY) 
. . 
- Likewise, Private Duty Nurses will not be
A 405 itgnuw From page 6 A 405 permitted to perform other professional
nursing duties inciuding flushing of an
(a and biOiOQlcaif-i tie intravenous line. The policy was reviewed
3% 'Stemd 0" under 0f: numan I with the Nurse Director group following the
yd ggtgaigsvf:g?giveai?gmanc? wl'tzfmera; revision. The Pavilion Nurse Director group
3 It . I Inc will review the amended poiicy with staff
.lia?lable licensing requirements, and . . .
a-  dance with the approved medica' Staff urlng an upcoming staff meetlng on 3/11/15.
Fl lb? :5 and procedures' The IndtVIduai nurse that took off the order to
permit the patient?s prIvate duty nurse to
- administer medications was counseled on the
3" TANDARD is not met as evidenced by; Private Duty Nurse Policy on 3/4/15.
IS ti on record review and staff interview. for The Pavilion Nurse Director will aiso review
Ci  ?Lt ten sampled patients (Patienti?i). the the Self-Administered Medication policy with
. jpttai failed to ensure that norsing staff staff on 3/11/15. included In the discussion
:Li 9?1th {0 12/19/14 that Patient will be appropriate documentation of the
I  9min? da'Ey madicat'ons were . medications. including documenting the
and 2) reponed to nursmg medications were self-administered by the
[romp that personai private staff were patient
nursing by accessing a peripherally
 tied central catheter (PICC).
- . i? do include:
illospital?s policies and procedures related to
r. ,i 9 Medication Administration indicated that
?mgistered nurse, licensed practical nurse
:dent nurse will administer medications to
EU a safe medication administration practices.
pital petioles and procedures related to
Self-Administration of Medications
 pitted that the physician will write an order for
at. {stir-grit to store medication at the bedside and
the medication. The policy
i, 9,4th the nurse will assess the patients ability
t. stirredminlster the ordered medications and 
?rse will record the medication as 

?l capital poiioy and procedure titled Private 5 
roam it! ltitrvaousVermont Obsoiete Event Facility ID: 2341 ifcontlnuatlcn ?n??bage 7 of 15?

 

 

 

 

 

 

62/24/2815 81:16 6172646366 PAGE 16/23

 

 

 

 

 

 

 

 

 

 

 

 

 

   
    
  
   
 
   
 

 

.  or: HEALTH AND HUMAN ?wag target's
CENTER a MEDICARE MEDICAID SERVICES ones: '09 avossr 
.iciENCIes 0(1) (X2) MULTIPLE CONSTRUCTION Ixai' SURVEY 
AND PLAN or . sonar: IDENTIFICATION NUMBER: LETED
I A. BUILDING I
A 220110 s. was :03" 5,2015 
NAME OF SUPPLIER STREET CITY. STATE. cone  
-. I 75 FRANCIS STREET
BRIGHAMWI. WOMEN HOSPITAL 3031.0"! MA 02115 A  1
(x4; Io  j; SUMMARY STATEMENT OF ID PLAN or CORRECTION i - pm; i
were .- I CH war as PREGEDED BY FULL peer-"Ix (EACH CORRECTIVE ACTION sacrum BE i
TAG 3  REGULATORY on TAG To THEAPPROPRIATE . MW 
DEFICIENCY) I
i a II 5 
A405 pinned From page 7 A405 5
?tter/sing Personnel indicated that private 1 i -
 jersonnel may assist in the care of patients 
as cars is limited to the provisions of - '1 . i
I titties of daily living and companionship
sills/tee.
EFL-hysioian Order. dated 6/7/14 at 3:53 PM. i a  
?ted that it was okay for the medications to . i
Eministered by Patient #4'3 personal staff 
trig to their schedule. The Order was

 

i to Hospital policy and procedure
f- [so private duty nurses may not administer
 tions to patients. The/Physician's Order

I gili?ensorlbed by a hospital registered nurse.

       
  
 
  
   

- hysician Order. dated 6/9/14 at 5:37 P.M..
tilled that Patient #4 may self-administer b:
the i'nedications, but all controlled substances I i
Milt/e administered by Hospital nurses. .

 .. tirveyor interviewed Registered Nurse #1 at
.1 on 1/13/15. Registered Nurse #1 said 3
a ient#4's personal staff identified
.-  elves as nurses.
.. uweyor interviewed Registered Nurse #3 at ,3 
QAM. on 1/13/15. Registered Nurse #3 said  
gents/4's personal staff identified themselves  
dress. Registered Nurse #3 said that Patient -  
. [personal staff administered oral, 
2% medications- Registered Nurse #3
,l at Patientnut's personal staff would then

"her a piece of paper with the date and time
. dirt #4 took his/her routine daily medioations.
5 tiered Nurse #3 said she would then enter
into Patient #4's electronic

I il-zttion administration record 



 

 

 



5bweyor Interviewed Registered Nurse #.Ltl

roam Sip/Previous Versions Obsolete Event ID: 015211 Facility ID: 2341 It continuation    

 

   

I I

NAME 

 
 



6172646366

 

 

I OF HEALTH AND HUMAN SERVICES
MEDICARE a. MEDICAID SERVICES

 

PAGE 17/23

 

dIsNCIas
TION

 

I


 

(X1) PROVIDERISUPPLIERICLIA
IDENTIFICATION NUMBER:

220110

 

(X2) MULTEPLE CONSTRUCTION

 

A. BUILDING

B. WING

 

 

 

 

 

I.

.1

SUPPLIER

.. 

fut/omens HOSPITAL

 

STREET ADDRESS. CITY. STATE. ZEP CODE
75 FRANCIS STREET
BOSTON, MA 02115

   

 

(X4SUMMARY STATEMENT or DEFICIENCIES

UH DEFICIENCY MUST BE PRECEDED BY FULL

I3 OR IDENTIFYING INFORMATION)

ID
PREFIX
TAG

PLAN OF CORRECTION i 'j i
(EACH CORRECTIVE ACTION SHOULD BE
TO THE APPROPRIAT
DEFICIENCV)



.I -
I




- his


goArIt

 

A 405

i



 

.M. on 1/14/15. Registered Nurse #4 said

Itier witnessed Patient #4 taking his routine
'Ons, Registered Nurse #4 said Patient

 

that Indicated the date and time

gslher medications. Registered

is would then enter the adminis



eonal staff provided her with a piece of

Patient #4
Nurse #4
lration into

.23? tvsyor interviewed Registered Nurse #5 at
livid. on 1/15/15. Registered Nurse #5 said
.  personal staff told her when Patient

gr: etion into Patient #4saw Patient #4 take his/her

 

 lived routine medications. Registered
. #5 said she would then enter the

I, iL?I?veyor interviewed Registered Nurse #6 at
- RM. on 1/20/15. Registered Nurse #6 said

rou?ne

dications. Registered Nurse #8 said
 's personal staff would give Patient #4
I outine daily medications. Registered

I said Patient #4'5 persona! staff told her
attent #4 received his/her medications and
?red Nurse #6 would enter the information

MAR.

tin review of dated 6/6/14 to


i"

Fifi, indicated Registered Nurse 

ared Nurse #5 and Registered Nurse #6

d:

a

ired Nurse Registered Nurse 

dated that they administered routine daliy

Iions to Patient#4. The did not

Id the medications were self-administered
,Exielnt #4 or his/her personal staff.

if aged Nurse #1 said Patient#4's
hed Petientir?zi?s PICC following fertlanyl

persona!

 sttratlon by Hospital registered nursesFORM Clue-ass:

 

 

 

(D

a.


 

I

Versions Obsolete

 

Event ID: 0115211

FadIlty ID: 2341

it:
if continuation tiff. 

I
I I
i. .

 

 

 

 

 

 61:16 6172646366  [18/23l

 

 

 

 

 

 

 

 

 

 

 

  
 
  

 

 

M. 1? i i 

DEPART  a: HEALTH AND HUMAN SERVICES . .7 '??fpg?ffgg -

CENTE s?  6 a MEDICAID SERVICES - emails?! 9 ?039:1 

(x1) (x2) MULTIPLE CONSTRUCTION ?alibi?. stain?y 1
AND :dmoN NUMBER: ABUILDWG  . 221110 awn/e  Tots 
NAME OF =11 1p aloe SUPPLIER STREETADDRESS. CITY. STATE. ZIP cone - 
i: 1 75 FRANCIS STREET i 1.

BRIGHA ?tell/l!le HOSPITAL BOSTON, MA 02115 3  i J. 
(x4) .9 -  SUMMARY STATEMENT OF DEFICIENCJES Io PROVIDERS PLAN or CORRECTION  i; :3 . 31x5) 
PREFIK DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE SHOULD BE . ., pot/irrenoNI 1

TAG . LATORY OR TAG CROSS-REFERENCED To THE WE 1
. I DEFICIENCY)  
5.4 x?  
A405 't died From page 9 A405 I   -
I i i
"1 Lira/:1 Nurse #3 said she observed Patient :i t; i
staff flushing Patient #4?5 PICC. II 5. 
dread Nurse #4 said Petlent #4'5 personal .  :3 
?shed Petiont#4's PICC. Registered 
#4 said she never provided the flush 
i. {ion to the personal staff because the I I  I .
gt?! staff had their own supplytveyor interviewed Hospital Physician #1 I  g: i
.1115 km. on 1/21/15. Physician #1 said he 1
 I Ilent #4's personal staff tit/sh Patient #4'5 11?- i
1, 
  . .
ILIl'i/eyor interviewed Nursing Director1/12/15. Nurse Director#1 said -   i. i 
I not think she reported to executive   
leadership that nursing staff were 
i medications administered by Patient 
j; Jeonal staff or that Patient #4?s private 3 i3
Ere accessing Patientr?i?s  


jut/lever interviewed Associate Chief Nurse I 
1:11:00 AM. on 1/13/15. Associate Chief 
#1 said Patient #4'5 visitors, guests and I
1 staff were not authorized to practice i- 
 ?lln the Hospital. 

  
    
  
 

 

i;

I i
.  eyor interviewed Associate Chief Nurse .. i. 
 :30 AM. on 1/14/15. Associate Chief ii . I
i, said she was not aware the Hospital 
staff were documenting the 

 

 

 

 

 ration of Patient #4?s routine daily 3 'i . i
 ions based on information provided by if it i 
$1.31; '3 personal staff orthat Patient #4?s   i
istaft were accessing Patient #4'3 PICC. 5  'i
A 502 gee/Irma) SECURE STORAGE A 5025 t? i i.
. I  2 item 
FORM Girls-zest 'ht?ttwiousVereiontiObaolote Event Facility?): 2341 lfoontinuatlon slit/?315182/24/2015 81:15 5172545355 PAGE 

DEPARFII I 33F HEALTH AND HUMAN tee/fem 
CENTE I  8t MEDICAID SERVICES  
I (X1) (sz MULTIPLE CONSTRUCTION i
AND PLAN (31  TION NumeER; AI BUILDWG 
I I A 220m: B. WING
NAME 0F 9 OR SUPPLIER STREET ADDRESS. CITY. STATESTREET BOSTON. MA 02115 - .
(x4) lD SUMMARY STATEMENT or PLAN OF CORRECTION Di?t MUST BE FRECEOED BY FULL PREFIX (EACH CORRECTIVE ACTION 8HOULD ee   
TAG 0R Leo IDENTIFYING INFORMATION) TAG CROSS-REFERENCE TO THE APPROPRIATI II  .9
II DEFICIENCY) Ii; 33 
- I Medication Security ?iI it 1 i
A502 I I med From page 10 A 502 The Pavilion Units (160 and 16D) have I  I I I i
purchased lockabie drawers for the unit.   I 
 dB and biologicele must be kept in a secure top drawer has a punch code lock for patieth   
Id locked when appropriate. medications. These are in placeevidenced by: it? -  
it on interview and record reviewfailed to ensure that medications for It  . I . if
  I I?ninlstietion were kept secure in a patient i:  I: 5
ti  tie required by Hospital poticiee and  I
three, for one often sampled patients  2-
I i
I Iii-?include:  -
:fii tiers poiiciee and procedures related to I 
edicatlon Administration and Patient .gIIgi .I .- 
of Medications indicated the .f I I
I lone ordered for self-administration will be i 55,- I 
iookeble storage container ever interviewed Registered Nurse #1 at ;Ej  
 .on 1/13/15. Registered Nurse #1 said I iti- I
'e routine medications were not kept in Si '35 
I  piece in room. 1: 3? 
1? - I
Iii"  a 
I eyor interviewed Registered Nurse #Iii/l. on 1/13/15. Registered Nurse #3 said i; i
-tf 'e routine medioetiene were kept in   33
I '3 room and Patientt?i took his/her own. 5; j;  . f.
It forte. Registered Nurse #3 said she had I -   '2 
 to do with the medications ordered for i; i; 3E
II  Inistretion. ii 
I  I
i eyor interviewed Registered Nurse #1/15/15. Registered Nurse #5 said Ir?   -
I I I 'not know where in Petientt?i's room ii;  5
I :routine daily medications were kept.  El: i
FORM Q: I-evious Versions Obsolete EVEN. ED: 0T5211 Facility 2341 {f continuation 3: 
. I
:l
i:  3 

 

 

 

 

 

   

 

 

92/24/2016 61:16 6172646366 PAGE 26/26

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

it"s-2: - 
II 
DEPART HEALTH AND HUMAN SERVICES 
CENTER I MEDICAID oust 938.0391 .
smeusm I IENCIES (x1) 1x2) MULTIPLE cossmucnou . x3 URY: 
AND PLAN or NUMBER: AI BUILDING sfeo 
I: ll Ei  . 
 220110 a. we I
NAME PR SUPPLIER CITY. STATE. ZIP cooa  ?2035f? 
. 7s 
RIGHAM HOSPITAL BOSTONI MA 02115 I  I
I i: i? SUMMARY A . g: 2'
Sigh ILL pa'??nx i it mitten
TAG OR L59 INFORMATION) TAG CROSS-REFERENCED TO THE mi": 2:
I I - DEFICIENCY) I   II
13 I: 
A 502 ,Ii'ILied From page 11 A 502  I . I 
fate Chief Nurse #1 was interviewed at i:  I
1 I rim. on 1/14/15. Associate Chief Nurse #1 I ii 
I bedside tables on Patient #4'3 nursing  it I
a. I ike the bedside tables on the other i:  1
Units. did not contain a drawer with a lock  . i
I II E: medications ordered for Si Iii-i i 5
A 7:49 -  am) INFECTION CONTROL A 749 Infection Control Practices for Precautions    I 
 i and Respiratory Protection   i I
i OtiOl?l control of?cer or officers must Respirator Fit Testing of Staff   i 5i
a System for identifyingr reporting. An interdisciplinaryIteam including memberig'f'ii ii
i Idaiing' an? continuing infections and of Infection Control, Environmental Affairs,  ii i I 
It gable (Masses of patients and I Nursing and Occupational Heanh   
Departments have been working together tciI  I
  develop and oversee a staff Fit Testing Ii  
?4 ANDARD is not met as evidenced by: progr?m' The team is engaged in the  {ii i .
I record review and interview? for 6 of6 followmg aspects of the program:   I 
I employees (Registered Nurse MI - Review of staff categories most Eikely to I I
I 9 and Hospital the Hospnal care for a patient on airborne precautions   i 5
i i ensure that staff consistently adhered to 1 Establish an education program to i; i 
i . practices including Hospital disseminate information to all staff on hospiiai-i i
. I for ?9?93?th and respiratory policy. requiring all caregivers providing   
II. qt FeqUirementS- I. under Airborne Precautions must complete?ijaif?ii 5 
. I respiratow medical screening with 't 5
$159 momde' Occupationai Health Service and use a   I I I
?i Hospital policy titled Contact Precautlon powered air reSpirator (PAPR) or a ?t tesieii  
. .eet, dated 8/2013. indicated multi-drug ?95 mask . .I
I 1: organisms required Contact - Develop a staff communIcatIon plan to:  I
- [ons_ The Hospital pansy indicated Clean 1. Remind staff that each staff member mu  I
ile isolation gowns must be worn Upon have undergone fit testing within the prior  i 
the room of a patient who is on Contact year to wear 3 N95 mask   
?ons. I 2. Remind staff to request a PAPR if caring, 
I i fo;r an airborne precaution patient and to  Ii 
I 5 Progress Now: dated I611 0/14: I request Just~ n~Time if needed I  
i  tie/Sh? was diagnosed With ?5 mUiti'dwg 3. Communicate to staff how to request Jl  Iiit;  i I
I I and placed on Contact Iestin it . I
FORM Revlousvaralona Obsolete Evant ID10T6211 Facility Io:2341 "continuation 8 ?gigs 11531}
 7i i 1
 . I 
iilit62/24/2815 81216

6172646366

tit
it

OF HEALTH AND HUMAN SERVICES

PAGE 21/23



?it? 

PRIN- - dam/20:16

 

 

 

 

 

 

 

 

"f

 

 

 

 

 

   

  

 

 

 

 

 

 

 

 

 

DEPART 
CFNTER EDICARE 8t MEDICAID SERVIC 
0 ?8 taaoset 
ENOIES (x1) x2 MULTIPLE CONSTRUCT it
AND PLAN OF NUMBER220110 e. WING I JAMS ii
NAME OF PR ji :iR OR SUPPLIER STREET ADDRESS. CITY, STATE. ZIP CODE i    
BRIGHAM ft omens HOSPITAL 7?5 FRANCE STREET 2 ii I '5
I is BOSTON, MA 02115 I . 
(X4) to i? SUMMARY STATEMENT or panoramas i . I it
PREFIX 3- Im DEFECIENQY MUST BE PREGEDED av FULL ?RlEf-?lx .   Ichg?ndh
TAG . - CROSS-REFERENCE TO THE ,3 DATE Improve access to database reports to  - '3
I gd From page 12 A 749 Administrators, Directors, Managers, and It} It
i: u' Iona Nurse-ln?Charge will have access to active 2? :33 
,i I list of staff that medicaily cleared and fit- i ii
I eyor Interwewed Nurse Director #1 at tested :ii?I I . 
:1 ?rfg?gstilg  Use of Personal Protective EQUipment nt#4 as If he/she was ctirty. Nurse  '?ticimg a Pat'e?? i i - 
1.0 #1 said etaftr were expected to adhere to Th  IS . ,gin-Q I 
i i of personal protective equipment. {e Defin?nznt I  
Inranewe Ste asaormenie ?onac;'? i
eyor interviewed Registered Nurse #3 at Precautions Fact Sheet"- The fact Sheet I  
1 .M. on 1/13/15. Registered Nurse #3 said guides Staff 0? the I?dication for Contact i a
5 I it not wear personal protective equipment Precautions, the type of patient room needtid i i
tering Patient #tt's room because Patient and the disease types for isolation, and 31,? '1
. -, sted that it not be worn. Registered states that all staff ?must use hand hygienei  
SaId she dId "0t Obsewe Other gowns, and gloves in order to enter the Hi  I
0 rs usln arsenal t' i I 
. 90 we eqummen patient room and remove such before leavi It; 4: 
i or a tent . the room? as indicated under the section eyor interviewed Registered Nurse #4 at Firm?? Prf?eft'v?? E??pg?j?anifms I 
7 a . on 1/14/15. Registered Nurse #4 said ormafon '8 a $0 Inc an?? OII ii I
was adamant about Staff not using Precautions available on the BWH infectio 1i 
i  gowns, Registered Nurse #4 said She Control website. in addition, Infection ConI .tg iI
t- veer isolation gowns when caring for staff 8'30 use a "?agging" System When IE it I
t' . patients are reported to the department as it 33;-
II
I i having an MDRO. Any staff member Ii  
a  Lt eyor Interviewed Begistered Nurse #7 at accessing a ??agged? patient?s medical 
- ?MC/fps- EeQISIe?red Nurse #7 sald record will see a red in LMR or a Dialogu Wet: PBf?Pheraliy ch Indicating the patient is on Contact Ilii' . I i
I CentraI Cameter (a PICC '8 an precautions for MRSA VRE or a resistant I
tous access that can be used for a t. I
'd_period of time) dressing and was not ?age we ac ena'  I
a I . anent #4 wag on Contact Precautions. This serves as another alert to staff that the  2' - 
 red Nurse #7 said she did not remember patient should be maintained on contact i? - 
a age Indicating precautions and she did  precautions. Nurses are also asked to i i] 
Ft an isolation gown when caring for provide isolation precaution educationat Hit} 1 'i
- materials to patient and familyeyor interviewed Physician #1 at 7:20 i  I
. 31 1/20/15. Physician #1 said he visited FORM anteater tater/iousvtarsicna Obsolete Event lDilJl?SZt?l Facility "3:23:11 ctii?fti' 'gei ts ofiil?
ii f:IIl i?I'Iisl . 

 

 

 

 

 

 

 

 

82/24/2615 61:15 5172646356 RAGE 22/HEALTH AND HUMAN SERVICES 
CENTE  MEDICARE MEDICAID SERVICES one? std-0391
53st? ENGIES (X1) x2 MULTIPLE consmuc?nos "i - I
AND PLAN (IF 33% ?trorv IDENTIFICATION NUMBER: SUILDING :220110 8- WING Mat-5.
NAMEIOF  on SUPPLIER CITY. STATE. ZIP cone I 1' 
. I ..-I i
., .1 HOSPITAL 75 FRANCE STREET STATEMENT 01" DEFICIENGIES ID PROVIDERS PLAN OF CORRECTION 'i W,
'f DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE 1?0 
TAG ;l We UIATORY 0R IDENTIFYING INFORMATION) TAG- CROSS-REFERENCE TO THE APPROPRIAT 1 
DEFICIENCY)  I i
I The Pavition unit staff nurses, PCAs, unit   
A 749 From page 13 A749 coordinator, and operations manager have  i' 
.  ?Ye to seven times weekly. physician been reminded of the guidefines, manuals 1' i i
re?t? 11.9 1101 wear an isolation gown and poticies located on the Infection Contro   
3  Patient#4 found it offensive. website. Physician #1 was aiso directed to  I
. i  the infection Control website. In particuiar.   
I   91/0: Intf?wlewed the Infequ they have been reminded of the availability: If  
- 3' to momtor Pa't'em #4 3 of Infection Control staff as a resource to .  I 
 3 PM. on 1/14/15. The Infection . . . . . . . I,
L: . . aSSIst them If dIffIcult Situations should arIs 
and She had no know'ec?ge Of re ardin adherence to ractices im ortant I i 
. I ?if. iprotectlve equipment not being used the Hospital poncy and Staff had not 0 In so Ion preven Ion. eclron ?ung had her about Patient re?educated staff on appropriate PPE I I 
selection. Their understanding and  
  eyor interviewed Nurse Director #1 at compliance of these guidelines had recently .  
 .Wl. on 1112/15. The Nurse Director said been assessed during Infection Control  
I .  traveled with a private cook, a personal Environment of Care Rounds performed .. i
i - . rift, F. 171: aPPlemately SIX (3) attendant staff 1/23/2015. Infection Control will continue tI 
1? 3  i ?31,111 a The Nurse assess staff understanding and compliance? i
12:11:13.3 .3101 Patten!? 5 51311 were I annualty and report back to the Nursing i' i
I 1.. nee of PatrentMs for his/her six (6) D?ectorofme Unit. i 
 dspitairzatlon. The Nurse Director #1 said I . i I
. referred to his/her personal staff as i I a
Ind the staff would participate in the direct -eyor intervrewed Registered Nurse #.on 1/13/15. Registered Nurse #1 said i 
.  a '5 personal staff would assist with ,i -. 
15 51'? 199-01 daily living care. 
[it .  
LT eyor interviewed Registered Nurse #3 at I I
Lb. on 1/13/15. Registered Nurse #3 said 3 i I
. risk: II's personal staff provided all of Patient l? 9
Imoluding routine medication I
ation. 
. I:  
eyor interviewed the infection Prevention . -E
 seplIaIEpIdemiologist, Infectious 
ll Infection Preventionists and . I 
Health Director) at 1:.1133.  1 - I1
.QRM amazes? i-j .-. out: Versions Obsolete Event Facility ID: 2341 If 51111?l I  111111?"3:3: I: It
3i", f' .I
E. ?11 'i

 

 

 

 

 

 

 

 

      

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

   

 

   
  
  
  
 

 

 

 

 

 

 

 

82/24/ 2615 81:18 6172645356 2-3/2?
- 2(13I2?l 5
DEPAR 3 HEALTH AND HUMAN SERVICES - PREV .3
EDICARE A MEDICAID SERVICES dual 3th
swemem ENGIES (x1) (x2) MULTEPLE CONSTRUCTION (er ?uhyev'll
AND PLAN cl .i-Ege TION NUMBER: A BUILDM terse 220110 9' WING adults I
NAME OF SUPPLIER smear ADDRESS. STATE. ZIP cone l.  
- -  {may 75 FRANCIS smear I 
02115 i i i! i
(mm i  UMMARYSTATEMENTOF ID PLAN oecoeaecuou ill (er 
gt? MUST BE PREGEDED oy FULL PREFIX ACTION SHOULD BE <0 
me i  I TORY TAG From page 14 A 749   
I 31'  'The Hospltal Epidemiologlsteeld the l; i 
13" M: I did not have any policies or procedures  ii
I  Iii-=3? greletlng to infection control or II i
1 1m? ;_Iatlon that addressed these personal I g; . i
 l"  3;
5:15? i? 4 Occupational Health Dlreotor said the  . I 5!
 _l polloy follows the requirements for I i!
'i testing of Hospital staff who wear an I a ll
tight-fitting facepieoe reapiretor).  j? 
till -  . 
1   eyor interviewed Registered Nurse #8 l? - 
fl, it; y't approximately 11 :00 AM. on 1/1511 5. ii . 
livl'fjft?f; :ed Nurses #8 and #9 said they Could i i 
t: a patient requiring them to use an 5 
.eyor reviewed the health files of i
it?? 'd Nurse #8 and'#9 on 1/20/15. 
 Nurse #8 and who said they would E. i
immediately don an N-QS particulate ii 3
 as needed, did not undergo fit testing  I
.l  00 and not annually as required the i] El
5 .: . Poticyu?w? .



 

 

 

 

I  I
i
.k  lvl.   - l, - . .
Foam sweet Event if continuation 

 

 

mum - 

 
    

. .

.

 

?BI/low Versions Obsolete

 

Facility ID: 2341