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Based on facility tours and interview with key personnel on August 21, 2013, between 08:30 and 15:00, it was determined that the facility failed to maintain the protective surfaces covering the examination table pads and rolling stools in the outpatient offices. These surfaces contained rips, tears and fraying of the corners which prevent them from being easily cleansed and sanitized.

Findings include:

1. Naples Family Practice; Examination table in Room 107, fraying corner on pad.
2. Bridgton Hospital Internal Medicine; Examination tables in Rooms #1 and #2, fraying corners on pad.
3. Bridgton Hospital Surgical Services; Examination table in Room across hall from lighthouse mural, fraying corners on pad.
4. Bridgton Hospital Pediatric Services; Examination table fraying corner on pad and rolling stool with torn surface in Room across hall from Nurse Manager's Office.
5. Bridgton Hospital Obstetrical and Gynecological Services; All exam tables contained fraying of the corners on the pad cover.
6. North Bridgton Family Practice: Examination tables in Rooms #2 and #3, fraying corners on pad covers.
7. These deficiencies were confirmed with the Director of Outpatient Services, Practice Manager, and Clinical Manager on August 21, 2013 between 08:00 and 15:00.

Based on a tour of the hospital with the Division Director of the Maintenance/ Construction on August 20 & 21, 2013, it was determined that not all the premises are clean and orderly.

Findings include:

1. In the Dietary Department
a. The dietary/kitchen area walls need to be painted.
b. The delivery carts were soiled with rusted wheels
c. There were several encrusted baking sheet pans.
d. The Hobart dish washing machine was encrusted with de-lime solution.
e. The floor corners throughout the dining room and kitchen area were soiled with dented or soiled cove bases.
f. The dividing, movable curtain in the dining room area was soiled, especially the area close to the floor.

2. The staff chairs at the nursing station in the Emergency Room were dusty and the Formica edge along the nurses desk was torn in places.

3. The boiler room was cluttered with items, making passage through certain areas of the room impassable. In addition, a door leading to the outside, was left wide open, allowing insects etc. access into the hospital. The screen door was found to be ill-fitting.

4. The carpet on the inpatient unit was worn around the nurses' station.

5. Several of supply rooms had dusty plastic bins that housed patient supplies.

6. In Operating Room #2, the cabinet storing scopes had a dusty bottom.

Based on facility tour of the Bridgton Hospital Outpatient Surgical Services and interview with key staff on August 21, 2013 at approximately 13:30 it was determined that the facility failed to maintain the confidentiality of patient record information against unauthorized use.

Findings include:

1. Paper records stored in a locked room behind the reception area were visible through the window of the room door. Patient names were clearly visible from outside the locked door.

2. This was confirmed by the Director of Outpatient Services on August 21, 2013 at approximately 13:30, who immediately had staff cover the window from the inside obscuring any ability to see the records.

Based on review of medical records and interviews with key staff on August 21, 2013, at approximately 3:15 p.m., it was determined that the facility failed to ensure that in those cases in which a Certified Registered Nurse Anesthetist (CRNA) administered the anesthesia, the anesthetist must be under the supervision of the operating practitioner, in five (5) of five (5) medical records. (RECORDS: MMM, NNN, OOO, PPP and QQQ).

Findings include:

1. Five (5) medical records were reviewed on August 21, 2013. None of the records contained the signature of the operating practitioner, which would indicate the necessary supervision.

2. During an interview with a CRNA on August 21, 2103, at approximately 3:15 p.m., he stated that since July 1, 2013, when the new computerized medical record system went live, none of the operating practitioners either don't have or don't know how to use passwords. He further stated that therefore the operating practitioners cannot sign forms.

3. The above findings were confirmed by the CRNA on August 21, 2013, at approximately 3:25 p.m.

Based on review of medical records and interviews with key staff on August 21, 2013, at approximately 1:30 p.m. and on August 22, 2013, at approximately 10:30 a.m., it was determined that the facility failed to document in two (2) of four (4) surgical records, that the patient was discharged in the company of a responsible adult. (RECORDS: MMM and NNN)

Findings include:

1. A review of surgical records on August 21 and 22, 2013, revealed that Records MMM and NNN did not contain any documentation that the patient had been discharged in the company of a responsible adult.

2. These findings were confirmed by a Registered Nurse in the Surgical Unit.

Based on review of policies and procedures, review of information provided and interviews with key staff on August 21, 2013, it was determined that the facility failed to incorporate the data collected regarding complaints and grievances into the hospital QAPI program.

Findings include:

1. On August 21, 2013, a review was made of the Clinical Practice Committee Meeting minutes from July 26, 2012 thru August 1, 2013. There was no discussion documented under the topic "Quality/Process improvement Team Reports (QAPI), of aggregated analyzed data related to complaints and grievances.

2. During an interview with the Manager, Guest Relations on August 21, 2013, at approximately 9:30 a.m., she stated that the data related to the complaints and grievances went to the Board of trustees but she didn't know if it went to the Clinical Practice Committee (QAPI).

3. During an interview with the Director Quality/PI on August 21, 2013, at approximately 10 a.m., she stated that the data from complaints and grievances did not go to the Clinical Practice Committee (QAPI).