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Based on observation of surveyor 16732 there are areas with interior finish that is not Class A or B with evidence as follows:

1) All phone pay phone booths on patients floors have peg board on the walls. Peg board has a rating of Class C finish.

2) Pediatric sedation has cedar shingles above door frame in the corridor.
3) Piece of 4'X8' of Styrofoam on back of fire door of mechanical AHU #3. (Removed on site)
4) Mechanical rooms have Zenolite Thermal insulation not covered.
5) Temporary construction wall in Emergency Room has blue styrofoam board exposed.

This standard was not met as evidenced by surveyor 11357 and the facility management staff.

On Nov 2, 2010 during a routine inspection of the Union Street Walk In Clinic, suite 4 the supply room door could not close and latch due to the movable supply rack leg sticking too far out into the travel path of the door. The supply room door must be kept closed when staff are not present. The door stop must be removed from the lower part of the door.


16732

Based on observation of surveyor 16732, following doors to corridor did not close properly with evidence as follows:

1) Smoke doors opening into to exit corridor on Grant 4.
2) 1 1/2 hour fire rated doors opening into exit corridor on Merritt 4 near payphone does not latch
3) Patient room door number 307 does not latch
4) Storage room on Grant 7 doors do not self close. One door help open with material at top and other wedged behind photocopier.
5) Self closer on house keep door Grant 8 has been removed

Based on observation of surveyor 16732, following hazardous area not properly protected with evidence as follows:

1) In the acute dialyses suite there is a repair person for electronic equipment.


20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. The following conditions were observed: 1)Grant level 7 nurses office/storage room behind the nurses station, the door going into the area was held open with a copier machine. This is a repeat deficiency from the 12/21/2007 survey; 2) Haskell level 3 laundry room door required to be self closing and positive latching; 3) Grant level 2 receiving area door going into storage room sticks and would not close properly; 4) Kelly level 1 Cath Lab, utility room door being held open by an improper device; 5) Keagan PACU area, sterile storage room door not closing and latching properly.

Based on observation of surveyor 16732, following exit access is not arranged for readily accessible with evidence as follows:

1) 8 th floor pediatric ICU to exit is obstructed with games that are being stored in the travel portion to the exit (Nintendo and other games)
2) 1st floor corridor on east side of emergency room has 9 stretchers stored in corridor. Stretchers have been in corridor for minimum of 24 hours.

Based on records review of the surveyor 16732, the written plan for the protectin of all patients and evacuation is not available to all supervisory personnel with evidence as follows:

1) In a random sample of floors, 2, 5, 6, 8 th floor nurses station has a diaster book that does not have the General Fire and Life Safety Procedures as provided by the Fire Protection Officer.
.

Based on observation of surveyor 16732, following area was not properly sprinklered with evidence as follows:

1) Sprinkler head in IS Grant 8 closet is obstructed by the ceiling tile.
2) Large combustible overhang on exterior of building from conference room on floor 2 does not have sprinkler protection.
3) There is no sprinkler coverage in IS Grant 7 closet.
4) Escutcheon plate missing from head on Grant 2 and pharmacy.
5) Freschias Kabi box stored within 18 inches of sprinkler head in pharmacy




20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. The following areas are not properly protected by the facility sprinkler system: I.S. section of Grant level 7, N.I.C.U section of Grant level 7, Labor & Delivery O.R. rooms 1, 2, & 3, and Main O.R. rooms1, 2, 5, 7, 8, 9, 11.

This standard was not met as evidenced by surveyor 11357 and the management staff.

On Nov 2, 2010, during a routine inspection of the Union Street Complex it was noted that a sprinkler room was cluttered with storage. The sprinkler pipes must be kept clear of obstructions to allow quick response and access in case of an emergency or Fire Department need. All sprinkler rooms must be kept clear of storage for at least 36 inches to allow access.

It was further noticed during a routine inspection of the Husson Internal Medicine on Nov 1, 2010 that the Obstruction Test of the sprinkler system has not been accomplished within the past five years.

It was further noticed during a routine inspection of 55 Broadway, Urological Surgery of Maine on Nov 1, 2010 that the sprinkler system had not been tagged indicating the date of the last inspection and what company accomplished the inspection. The date of flushing/obstruction test was also missing from the stand pipe

Based on observation and records review of surveyor 16732, the commerical cooking hood is not being maintained in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operation with evidence as follows:

1) There are no certificiate of inspections.
2) There are no certificates of cleaning.
3) There is no label indicating the date cleaned and the name of the servicing company, and areas not cleaned.
4)



20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that the kitchen hood located behind the grill area of the serving line contained an excessive amount of grease build up from the filter area out. Records could not be found as to the last cleaning date of the system nor was the hood tagged to show the last and next cleaning dates. Hoods are to be cleaned a minimum of every 6 months or more often if necessary as determined by the authority having jurisdiction, records kept of the cleaning and hoods are to be marked as to the last cleaning date and next due cleaning date.

This tag not met as observed by this surveyor and the facility Fire Protection Safety Manager. It was observed that in the center exit access corridor of the P.A.C.U. unit in the Keagan building the two exits leading out of the unit were partially blocked by carts and supplies making it very diffucult access the exit. Means of egress are to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects are to obstruct exits, access to, egress from, or visibility of exits.

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that several compustible seasonal decorations were hanging on the corridor walls of Haskell level 3, Rehab area.

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that in the P.A.C.U suite area of Keagan building, that three soiled linen utility carts were being stored in one of the suites areas. Each of the carts have a capacity of greater than 32 gallons. In talking with staff they stated that they use a lot of linen and the carts were being used for soiled linen. Reference states that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are to be located in a room protected as a hazardous area when not attended. 19.7.5.5

This standard was not met as evidenced by surveyor 11357 and the facility manager.

On Nov 2, 2010 during a routine inspection of the Union Street Complex in the Family Practice Wing an unsecured bottle of nitrous oxide was discovered. The medical gas must be secure at all times to insure for the safety of the personnel near the gas.

It was further noted the an "E" tank of oxygen was discovered in the ED Triage area of the main hospital on State Street on Nov 3,2010 during a routine inspection.. The oxygen tank was observe to be on it's side and unsecured.


16732

Based on observation of surveyor 16732, oxygen is not being properly stored with evidence as follows:


1) There is plywood on the walls approximate 4 ft in height.
2) Chain used to secure tanks was not tight
3) Door leading to mechanical room is not fire rated.

This standard was not met as evidenced by surveyor 11357 and the facility management.

On Nov 2, 1020 during a routine inspection of Suite 215 of the Union Street Complex it was observed that a hasp and lock was being utilized to secure the records room. The hasp locking devise must be removed and other means should be used to secure the records room. The hasp locking devise could easily trap an individual inside the room, preventing escape.


16732



20980

The following additional deficiencies were discovered; 1) In the Webber building West, levels two and three, door wedges were found blocking the doors open. 2) Blocked access to electrical panels in OR three and Labor & Delivery rooms #2 & 3.

This standard was not meet as evidenced by surveyor 11357 and the facility management.

On Nov 1, 2010 during a routine inspection of EMMC Orono Family Medicine, 84 Kelly Rd, Orono it was observed that the Utility closet had combustibles liquids loose in the area. The combustibles must be placed in a metal locker in a safe area.

20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that the following areas were improperly using extension cords/power strips: Room #5 in N.I.C.U. and the corridor of the level 3 in the Kelly building.

Based on observation of surveyor 16732 there are areas with interior finish that is not Class A or B with evidence as follows:

1) All phone pay phone booths on patients floors have peg board on the walls. Peg board has a rating of Class C finish.

2) Pediatric sedation has cedar shingles above door frame in the corridor.
3) Piece of 4'X8' of Styrofoam on back of fire door of mechanical AHU #3. (Removed on site)
4) Mechanical rooms have Zenolite Thermal insulation not covered.
5) Temporary construction wall in Emergency Room has blue styrofoam board exposed.

This standard was not met as evidenced by surveyor 11357 and the facility management staff.

On Nov 2, 2010 during a routine inspection of the Union Street Walk In Clinic, suite 4 the supply room door could not close and latch due to the movable supply rack leg sticking too far out into the travel path of the door. The supply room door must be kept closed when staff are not present. The door stop must be removed from the lower part of the door.


16732

Based on observation of surveyor 16732, following doors to corridor did not close properly with evidence as follows:

1) Smoke doors opening into to exit corridor on Grant 4.
2) 1 1/2 hour fire rated doors opening into exit corridor on Merritt 4 near payphone does not latch
3) Patient room door number 307 does not latch
4) Storage room on Grant 7 doors do not self close. One door help open with material at top and other wedged behind photocopier.
5) Self closer on house keep door Grant 8 has been removed

Based on observation of surveyor 16732, following hazardous area not properly protected with evidence as follows:

1) In the acute dialyses suite there is a repair person for electronic equipment.


20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. The following conditions were observed: 1)Grant level 7 nurses office/storage room behind the nurses station, the door going into the area was held open with a copier machine. This is a repeat deficiency from the 12/21/2007 survey; 2) Haskell level 3 laundry room door required to be self closing and positive latching; 3) Grant level 2 receiving area door going into storage room sticks and would not close properly; 4) Kelly level 1 Cath Lab, utility room door being held open by an improper device; 5) Keagan PACU area, sterile storage room door not closing and latching properly.

Based on observation of surveyor 16732, following exit access is not arranged for readily accessible with evidence as follows:

1) 8 th floor pediatric ICU to exit is obstructed with games that are being stored in the travel portion to the exit (Nintendo and other games)
2) 1st floor corridor on east side of emergency room has 9 stretchers stored in corridor. Stretchers have been in corridor for minimum of 24 hours.

Based on records review of the surveyor 16732, the written plan for the protectin of all patients and evacuation is not available to all supervisory personnel with evidence as follows:

1) In a random sample of floors, 2, 5, 6, 8 th floor nurses station has a diaster book that does not have the General Fire and Life Safety Procedures as provided by the Fire Protection Officer.
.

Based on observation of surveyor 16732, following area was not properly sprinklered with evidence as follows:

1) Sprinkler head in IS Grant 8 closet is obstructed by the ceiling tile.
2) Large combustible overhang on exterior of building from conference room on floor 2 does not have sprinkler protection.
3) There is no sprinkler coverage in IS Grant 7 closet.
4) Escutcheon plate missing from head on Grant 2 and pharmacy.
5) Freschias Kabi box stored within 18 inches of sprinkler head in pharmacy




20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. The following areas are not properly protected by the facility sprinkler system: I.S. section of Grant level 7, N.I.C.U section of Grant level 7, Labor & Delivery O.R. rooms 1, 2, & 3, and Main O.R. rooms1, 2, 5, 7, 8, 9, 11.

This standard was not met as evidenced by surveyor 11357 and the management staff.

On Nov 2, 2010, during a routine inspection of the Union Street Complex it was noted that a sprinkler room was cluttered with storage. The sprinkler pipes must be kept clear of obstructions to allow quick response and access in case of an emergency or Fire Department need. All sprinkler rooms must be kept clear of storage for at least 36 inches to allow access.

It was further noticed during a routine inspection of the Husson Internal Medicine on Nov 1, 2010 that the Obstruction Test of the sprinkler system has not been accomplished within the past five years.

It was further noticed during a routine inspection of 55 Broadway, Urological Surgery of Maine on Nov 1, 2010 that the sprinkler system had not been tagged indicating the date of the last inspection and what company accomplished the inspection. The date of flushing/obstruction test was also missing from the stand pipe

Based on observation and records review of surveyor 16732, the commerical cooking hood is not being maintained in accordance with NFPA 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operation with evidence as follows:

1) There are no certificiate of inspections.
2) There are no certificates of cleaning.
3) There is no label indicating the date cleaned and the name of the servicing company, and areas not cleaned.
4)



20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that the kitchen hood located behind the grill area of the serving line contained an excessive amount of grease build up from the filter area out. Records could not be found as to the last cleaning date of the system nor was the hood tagged to show the last and next cleaning dates. Hoods are to be cleaned a minimum of every 6 months or more often if necessary as determined by the authority having jurisdiction, records kept of the cleaning and hoods are to be marked as to the last cleaning date and next due cleaning date.

This tag not met as observed by this surveyor and the facility Fire Protection Safety Manager. It was observed that in the center exit access corridor of the P.A.C.U. unit in the Keagan building the two exits leading out of the unit were partially blocked by carts and supplies making it very diffucult access the exit. Means of egress are to be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects are to obstruct exits, access to, egress from, or visibility of exits.

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that several compustible seasonal decorations were hanging on the corridor walls of Haskell level 3, Rehab area.

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that in the P.A.C.U suite area of Keagan building, that three soiled linen utility carts were being stored in one of the suites areas. Each of the carts have a capacity of greater than 32 gallons. In talking with staff they stated that they use a lot of linen and the carts were being used for soiled linen. Reference states that mobile soiled linen or trash collection receptacles with capacities greater than 32 gal (121 L) are to be located in a room protected as a hazardous area when not attended. 19.7.5.5

This standard was not met as evidenced by surveyor 11357 and the facility manager.

On Nov 2, 2010 during a routine inspection of the Union Street Complex in the Family Practice Wing an unsecured bottle of nitrous oxide was discovered. The medical gas must be secure at all times to insure for the safety of the personnel near the gas.

It was further noted the an "E" tank of oxygen was discovered in the ED Triage area of the main hospital on State Street on Nov 3,2010 during a routine inspection.. The oxygen tank was observe to be on it's side and unsecured.


16732

Based on observation of surveyor 16732, oxygen is not being properly stored with evidence as follows:


1) There is plywood on the walls approximate 4 ft in height.
2) Chain used to secure tanks was not tight
3) Door leading to mechanical room is not fire rated.

This standard was not met as evidenced by surveyor 11357 and the facility management.

On Nov 2, 1020 during a routine inspection of Suite 215 of the Union Street Complex it was observed that a hasp and lock was being utilized to secure the records room. The hasp locking devise must be removed and other means should be used to secure the records room. The hasp locking devise could easily trap an individual inside the room, preventing escape.


16732



20980

The following additional deficiencies were discovered; 1) In the Webber building West, levels two and three, door wedges were found blocking the doors open. 2) Blocked access to electrical panels in OR three and Labor & Delivery rooms #2 & 3.

This standard was not meet as evidenced by surveyor 11357 and the facility management.

On Nov 1, 2010 during a routine inspection of EMMC Orono Family Medicine, 84 Kelly Rd, Orono it was observed that the Utility closet had combustibles liquids loose in the area. The combustibles must be placed in a metal locker in a safe area.

20980

This tag not met as observed by this surveyor and the Fire Protection Safety Manager. It was observed that the following areas were improperly using extension cords/power strips: Room #5 in N.I.C.U. and the corridor of the level 3 in the Kelly building.