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Based on observation and interview, the facility failed to ensure that expired medications were removed from availability in the emergency department.

Finding:
On 10/20/15 at approximately 2:15 PM, during a tour of the emergency department, the surveyor observed 4 bottles of piperacillin-tazobactam intravenous injection within the Pyxis medication system with an expiration date of October 1, 2015. This finding was confirmed with the Emergency Department Nurse Manager at the time of the observation.

Based on a tour of the facility, review of records, and interviews with key personnel on October 20 and 21, 2015, it was determined that the facility failed to maintain the facility to ensure the safety of patients.

Findings include:
1. On 10/20/15 at 8:10 AM, during a tour of the Women's Health Center, 2 stained ceiling tiles were observed in the Bone Density Room, indicating a water leak had occurred, increasing the risk of mold growth. These findings were confirmed at that time with the Director of Information Technology and Plant Operations.

2. On 10/20/15 at 8:35 AM, during a tour of Pediatrics, the bottom of the cabinet under the sink drain in Room # 3 was observed to be stained and water damaged indicating a water leak had occurred, increasing the risk of mold growth. Additionally a hole in the floor covered with tape was observed near the toilet in the bathroom of the waiting room, resulting in that area of the floor being uncleanable. These findings were confirmed at that time with the Director of Information Technology and Plant Operations.

3. On 10/20/15 at 10:00 AM, during a tour of the Computerized Tomography (CT) Room, a tray table with paint missing on its base and 4 rusty casters was observed, creating uncleanable surfaces. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

4. On 10/20/15 at 10:35 AM, during a tour of the Laboratory, A wooden base under the hazardous waste receptacle was observed to be missing paint, exposing bare wood, and creating an uncleanable surface. Additionally, unpainted edges on a piece of wood, under the hematology scope table, was observed at that time, which created uncleanable surfaces. These findings were confirmed at that time with the Director of Information Technology and Plant Operations.

5. On 10/20/15 at 1:25 PM, during a tour of the Cardiac Rehabilitation Gym, a grab bar with numerous cracks on both ends was observed on the treadmill, creating uncleanable surfaces. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

6. On 10/20/15 at 1:30 PM, during a tour of the Nuclear Medicine Room, 1 stained ceiling tile was observed, indicating a water leak had occurred, increasing the risk of mold growth. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

7. On 10/20/15 at 1:35 PM, during a tour of the Information Technology Closet, 2 stained ceiling tiles were observed, indicating a water leak had occurred, increasing the risk of mold growth. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

8. On 10/20/15 at 1:40 PM, during a tour of the Housekeeping Closet, 1 stained ceiling tile was observed, indicating a water leak had occurred, increasing the risk of mold growth. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

9. On 10/20/15 at 3:00 PM, during a tour of the Ambulatory Surgical Unit, the stretchers in Bay 3, Bay 8, and Bay 10 were observed to have rust around the base of the I.V. poles, creating uncleanable surfaces. These findings were confirmed at that time with the Director of Information Technology and Plant Operations.

10. On 10/21/15 at 8:45 AM, during a tour of The Obstetrics Unit, a mold-like stain was observed along the bottom seam of the shower curtains in Room # 257 and Room # 259. These findings were confirmed at that time with the Director of Information Technology and Plant Operations.

11. On 10/21/15 at 1:40 PM, during a tour of the Medical/Surgical Unit, an Intravenous Pole with 4 rusty casters, creating uncleanable surfaces, was observed in Room # 219. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

12. State of Maine Plumbing Code, Chapter 238, Section 11.C.2.e requires that direct connections between potable water piping and sewer connected wastes shall not exist under any condition, with or without back flow protection. The air gap that is required by this code was not found in the drain plumbing of the ice machines observed during a tour of the facility on 10/20/15 at 1:45 PM in the Café, on 10/20/15 at 3:15 PM in the Post Anesthesia Care Unit (PACU), and on 10/21/15 at 9:10 AM in the Medical/Surgical Unit nourishment area. These findings were confirmed at the times of the observations with the Director of Information Technology and Plant Operations.

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Based on observation and interviews with key personnel on October 20 and 21, 2015, it was determined that the facility failed to effectively monitor hospital disinfection practices, and environment of care surveillance.

Findings:
1. On 10/20/15 at 8:07 AM during a tour of Women's Health, a deposit of a dark colored, organic appearing substance was observed near the center of the clean exam table in the Bone Density Room. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

2. On 10/20/15 at 3:00 PM, during a tour of the Cardiac Rehabilitation Unit, a tray table located in the bathroom, was observed to have deposits of a gel-like substance. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

3. On 10/20/15 at 3:00 PM, during a tour of the Ambulatory Surgical Unit, the foot end of the clean stretcher frames in Bay 8 and Bay 10 were observed to have organic-appearing, brownish deposits. This finding was confirmed at that time with the Director of Information Technology and Plant Operations.

4. On 10/20/15 at approximately 9:15 AM, during a tour of the emergency department, the surveyor observed the emergency eye wash station in exam room 6 had black plastic water head nozzles that appeared dirty and the water flow pores appeared clogged with a white substance. This finding was confirmed with the Emergency Department Nurse Manager at the time of the finding.

5. On 10/20/15 at approximately 10:15 AM, during a tour of the emergency department, the surveyor observed that the portable electronic medical record documentation work station labeled as ED Work Station #4 had a large light brown dried liquid ring stain consistent with a coffee cup stain on its work station. This finding was confirmed with the Emergency Department Nurse Manager at the time of the finding.

6. On 10/20/15 at approximately 10:15 AM, during a tour of the emergency department, the surveyor observed that the portable ultrasound machine had patient probes that were covered in a white substance that appeared to be consistent with dried ultrasound gel. This finding was indicative of a probe that was stored without being cleaned after patient use and had dried ultrasound gel on it. This finding was confirmed with the Emergency Department Nurse Manager at the time of the finding.