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Based on a tour of the facility, review of records, and interviews with key personnel on December 14-15, 2015, it was determined that the facility failed to maintain the facility in a manner to ensure the safety of patients.

The finding includes:

On December 14, 2015, on a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), stained ceiling tiles were observed in the following areas:
· Intensive Care Telemetry Room 5 (one tile)
· Medical Surgical Room 219 (one tile)
· X-Ray Room 2 (three tiles)
· Stress Test Room (one tile)

· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14, 2015, on a tour of the facility with the SP/EPC, worn, weathered, unsealed window sill surfaces, not easily cleansed and sanitized, were observed:
· In the patient rooms of the Intensive Care area
· Medical Surgical Room 219
· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14, 2015, a surveyor reported that the window sills in the Emergency Department patient rooms were worn, weathered and not sealed.
· This finding was confirmed at the time of the findings with the Emergency Department Manager.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, equipment with rusty bases or casters, having surfaces not easily cleansed or sanitized, were observed:
· Obstetrics Room 308 (two Intravenous (IV) Poles )
· Medical/Surgical Room 213 (one IV Pole)
· Critical Care (CC) Room 1 (three IV poles)
· CC Room 4 (one IV pole)
· Computed Tomography (CT) Room (one IV pole)
· Operating Room 1 (one table and one stool)
· Operating Room 2 (one ring stand, two IV poles, and one stool)
· Operating Room 3 (one IV pole)
· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, damage to walls sills, and rails was observed, creating uncleanable surfaces:
· Medical/Surgical Room 209 (an approximately one inch by one half inch gouge into the wall behind the toilet in the bathroom
· CT Room (gouge into the wall and damage to the wall by the toilet of the CT Changing Room)
· Ultrasound Room (a line of damage into the wall at chair-back height, behind the chair and a line of wall damage near the stretcher)
· Microbiology Area of the Laboratory (missing paint on the column)
· Room 1 of Lincoln Medical Partners (LMP) Orthopedics (area of missing paint on the wall and an unfinished wall patch
· Semi-Restricted Area of the Operating Room area (near the scrub station, to the right of the Pyxis Medicine Station, and in the storage area, many scrapes, gouges, and missing paint)
· Operating Room 1 (the window sill was missing paint in numerous areas)
· Operating Room 2 (multiple areas of scrapes, gouges, and missing paint)
· Post Anesthesia Care Unit (PACU) (the bottom edge of the wooden rails was badly damaged)
· Operating Room 3 (the lower wall opposite the door had multiple gouges and the wall to the left of the door over the cove base was damaged)
· This finding was confirmed at the time of the observations by the SP/EPC.


On December 14, 2015, a surveyor reported that the Emergency Department had numerous areas where there were scarred and damaged walls, missing paint and exposed sheet rock throughout the area. These findings were confirmed at the time of the findings with the Emergency Department Manager.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, damaged floors creating uncleanable surfaces were observed:
· Laboratory (worn and cracked floor tiles throughout the area)
· X-Ray Room 2 (3 cracked floor tiles)
· Ultrasound Room 2 (two cracked floor tiles)
· Outside of the stress Test Room (three cracked floor tiles)
· Bathroom of CC Room 4 (two cracked floor tiles under the sink)
· Triage Room (two cracked floor tiles inside the room and 10 damaged floor tiles directly outside the room)
· LMP Women's Center in Room 204 (a cracked floor tile in front of the cabinet and a large gap between floor tiles to the left of the door), and Room 206 (a large gap between floor tiles to the left in front of the windows)
· LMP Orthopedics in the Patient Bathroom (caulking around the toilet in the bathroom was cracked and pulled away from the toilet)
· This finding was confirmed at the time of the observations by the SP/EPC.

Based on a tour of the facility, interviews with key personnel, and information provided by the facility on December 16, 2015, it was determined that the facility failed to assure that a sufficient emergency water supply was available.

The finding includes:

In A Memorandum of Agreement (MOA) between the facility and Nestle Water which was provided to the surveyor by the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC) on December 16, 2015. Nestle water, who is the primary supplier of emergency water, recommended in this MOA that the facility keep at least a twenty four hour supply (of water) on hand at all times.

On December 16, 2015 at approximately 10:00 AM, in an interview with the Food Service Director (FSD) and the SP/EPC, the FSD stated that they did not have a twenty four hour water supply available at that time. The SP/EPC stated that she did not know how much they needed to have on hand.

Based on observation and review of policies and interviews with key staff on December 14, 2015, it was determined that the CAH failed to implement policies assuring that health care is provided in a safe environment.

The finding includes:

During a tour of the Emergency Department on December 14, 2015 at approximately 11:00 AM, it was observed that one of two rooms (Room #3) used for psychiatric patients failed to assure that patient safety could be maintained at all times. This room contained mini-blinds which contained cords that could be attached to fixed objects on in the room allowing a patient to potentially harm themselves.

The hospital policy "Patient at Risk for Harm and/or Elopement (Hospital Management)"; states "The patient will be placed in a designated safe room and or the most appropriate room to facilitate monitoring... When possible, rooms 2 and 3 will be used. Rooms to be cleared and of items, cabinets locked."

The room contained a real time video surveillance system of the patients to monitor for self harm; however, the Emergency Department Manager stated that she was not able to guarantee that patients would be under video surveillance at all times.

Based on a tour of the facility and policy review on December 14, 2015, it was determined that the facility failed to keep horizontal surfaces clean, increasing the risk of the spread of infectious organisms.
The finding includes:
Facility Policy 05.6900.044 Standard Cleaning Procedures, III Cleaning Procedures: C. High Dusting: a. Using a high duster and beginning at door and proceeding counter clockwise around the room, dust all surfaces above shoulder height. Include tops of lights, doors, curtain tracks, clocks and high TVs, and window blinds.
On December 14, 2015, during a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), high dust was found on horizontal surfaces between 11:40 AM and 12:20 PM:
· Top surfaces of the light over the second bed and on the top surface of the television monitor in Obstetrics Room 308
· Top edge of the wall-mounted mirror and on the top surface of the light that was over the bed in Obstetrics Room 306
· Top surface of the television monitor and top surface of the light that was over the bed in Obstetrics Room 305
· Top surface of the cabinet, the wall-hung picture, and the light over the bed in Obstetrics Room 302
· Top surface of the cabinet and the television monitor in Intensive Care Room 2
· Top of the television monitor in Intensive Care Room 3
· Top surface of the cabinet doors in Intensive Care Telemetry Room 5
· Top surfaces of the wall-hung picture and the white/communication board in Medical/Surgical Room 209
· Top surfaces of a wall-hung picture, television monitor, white/communication board
· Top surface of the light over the bed in Medical/Surgical Room 205
· Top surfaces of the closet door and the television monitor in Medical/Surgical Room 219
· Top surfaces of the television monitor in Medical/ Surgical Room 216
· Top surfaces of the arms holding the television monitor in Ambulatory Surgical Unit Rooms 4, 7, and 8
· Top surfaces of the cabinet and the arm that holds the light that extends over the bed in Critical Care (CC) Room 1, on the top surface of the arm that holds the light that extends over the bed in CC Room 2
· Top surface of the cabinets in the Orthopedic Room and in CC Room 4
· This finding was confirmed at the time of the observations by the SP/EPC.

Based on a tour of the facility, policy review, and interview with key personnel on December 14, 2015, it was determined that the facility failed to be in compliance with food service standards and failed to follow facility procedures to assure that outdated food was not available for use for patient consumption.
The Finding includes:

· 2013 Maine Food states in 4-601.11 (A): Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils:
(A) Equipment Food-Contact surfaces shall be clean to sight and touch.
(C) Non-Food-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, Food residue and other debris.

· Facility Policy Number: 09.6070-IC-5007, Infection Control, Dietary Department; III Procedure: C. Environment; 2. All equipment shall be thoroughly cleaned after each use.

· On December 14, 2015, at approximately 10:15 AM, a meat slicer was observed to have food debris left on the blade and the base.

· This finding was confirmed at the time of the finding by the Food Service Director.

· Facility Policy Number: 05.6780.04: Subject: Par Stock Nourishments. Procedure: 6. Perishable food items will be dated for expiration three days out from opening/preparation. 7. Dietary is responsible for removing outdated items and returning them to the kitchen to be disposed of properly.

· On December 14, 2015, at approximately 1:00 PM, during a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), the following items were found out of compliance with hospital policy:

· An opened bottle of prune juice, dated opened "11/20", an opened bottle of cranberry juice with no label visible indicating when it was opened, and an unlabeled/undated, refillable, plastic, screw capped bottle with a reddish liquid were observed in the Intensive Care Unit patient refrigerator.

· This finding was confirmed at that time and immediately removed from use and disposed of by the SP/EPC.

Based on a tour of the facility, review of records, and interviews with key personnel on December 14-15, 2015, it was determined that the facility failed to maintain the facility in a manner to ensure the safety of patients.

The finding includes:

On December 14, 2015, on a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), stained ceiling tiles were observed in the following areas:
· Intensive Care Telemetry Room 5 (one tile)
· Medical Surgical Room 219 (one tile)
· X-Ray Room 2 (three tiles)
· Stress Test Room (one tile)

· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14, 2015, on a tour of the facility with the SP/EPC, worn, weathered, unsealed window sill surfaces, not easily cleansed and sanitized, were observed:
· In the patient rooms of the Intensive Care area
· Medical Surgical Room 219
· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14, 2015, a surveyor reported that the window sills in the Emergency Department patient rooms were worn, weathered and not sealed.
· This finding was confirmed at the time of the findings with the Emergency Department Manager.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, equipment with rusty bases or casters, having surfaces not easily cleansed or sanitized, were observed:
· Obstetrics Room 308 (two Intravenous (IV) Poles )
· Medical/Surgical Room 213 (one IV Pole)
· Critical Care (CC) Room 1 (three IV poles)
· CC Room 4 (one IV pole)
· Computed Tomography (CT) Room (one IV pole)
· Operating Room 1 (one table and one stool)
· Operating Room 2 (one ring stand, two IV poles, and one stool)
· Operating Room 3 (one IV pole)
· This finding was confirmed at the time of the observations by the SP/EPC.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, damage to walls sills, and rails was observed, creating uncleanable surfaces:
· Medical/Surgical Room 209 (an approximately one inch by one half inch gouge into the wall behind the toilet in the bathroom
· CT Room (gouge into the wall and damage to the wall by the toilet of the CT Changing Room)
· Ultrasound Room (a line of damage into the wall at chair-back height, behind the chair and a line of wall damage near the stretcher)
· Microbiology Area of the Laboratory (missing paint on the column)
· Room 1 of Lincoln Medical Partners (LMP) Orthopedics (area of missing paint on the wall and an unfinished wall patch
· Semi-Restricted Area of the Operating Room area (near the scrub station, to the right of the Pyxis Medicine Station, and in the storage area, many scrapes, gouges, and missing paint)
· Operating Room 1 (the window sill was missing paint in numerous areas)
· Operating Room 2 (multiple areas of scrapes, gouges, and missing paint)
· Post Anesthesia Care Unit (PACU) (the bottom edge of the wooden rails was badly damaged)
· Operating Room 3 (the lower wall opposite the door had multiple gouges and the wall to the left of the door over the cove base was damaged)
· This finding was confirmed at the time of the observations by the SP/EPC.


On December 14, 2015, a surveyor reported that the Emergency Department had numerous areas where there were scarred and damaged walls, missing paint and exposed sheet rock throughout the area. These findings were confirmed at the time of the findings with the Emergency Department Manager.

On December 14-15, 2015, on a tour of the facility and outpatient areas with the SP/EPC, damaged floors creating uncleanable surfaces were observed:
· Laboratory (worn and cracked floor tiles throughout the area)
· X-Ray Room 2 (3 cracked floor tiles)
· Ultrasound Room 2 (two cracked floor tiles)
· Outside of the stress Test Room (three cracked floor tiles)
· Bathroom of CC Room 4 (two cracked floor tiles under the sink)
· Triage Room (two cracked floor tiles inside the room and 10 damaged floor tiles directly outside the room)
· LMP Women's Center in Room 204 (a cracked floor tile in front of the cabinet and a large gap between floor tiles to the left of the door), and Room 206 (a large gap between floor tiles to the left in front of the windows)
· LMP Orthopedics in the Patient Bathroom (caulking around the toilet in the bathroom was cracked and pulled away from the toilet)
· This finding was confirmed at the time of the observations by the SP/EPC.

Based on a tour of the facility, interviews with key personnel, and information provided by the facility on December 16, 2015, it was determined that the facility failed to assure that a sufficient emergency water supply was available.

The finding includes:

In A Memorandum of Agreement (MOA) between the facility and Nestle Water which was provided to the surveyor by the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC) on December 16, 2015. Nestle water, who is the primary supplier of emergency water, recommended in this MOA that the facility keep at least a twenty four hour supply (of water) on hand at all times.

On December 16, 2015 at approximately 10:00 AM, in an interview with the Food Service Director (FSD) and the SP/EPC, the FSD stated that they did not have a twenty four hour water supply available at that time. The SP/EPC stated that she did not know how much they needed to have on hand.

Based on observation and review of policies and interviews with key staff on December 14, 2015, it was determined that the CAH failed to implement policies assuring that health care is provided in a safe environment.

The finding includes:

During a tour of the Emergency Department on December 14, 2015 at approximately 11:00 AM, it was observed that one of two rooms (Room #3) used for psychiatric patients failed to assure that patient safety could be maintained at all times. This room contained mini-blinds which contained cords that could be attached to fixed objects on in the room allowing a patient to potentially harm themselves.

The hospital policy "Patient at Risk for Harm and/or Elopement (Hospital Management)"; states "The patient will be placed in a designated safe room and or the most appropriate room to facilitate monitoring... When possible, rooms 2 and 3 will be used. Rooms to be cleared and of items, cabinets locked."

The room contained a real time video surveillance system of the patients to monitor for self harm; however, the Emergency Department Manager stated that she was not able to guarantee that patients would be under video surveillance at all times.

Based on a tour of the facility and policy review on December 14, 2015, it was determined that the facility failed to keep horizontal surfaces clean, increasing the risk of the spread of infectious organisms.
The finding includes:
Facility Policy 05.6900.044 Standard Cleaning Procedures, III Cleaning Procedures: C. High Dusting: a. Using a high duster and beginning at door and proceeding counter clockwise around the room, dust all surfaces above shoulder height. Include tops of lights, doors, curtain tracks, clocks and high TVs, and window blinds.
On December 14, 2015, during a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), high dust was found on horizontal surfaces between 11:40 AM and 12:20 PM:
· Top surfaces of the light over the second bed and on the top surface of the television monitor in Obstetrics Room 308
· Top edge of the wall-mounted mirror and on the top surface of the light that was over the bed in Obstetrics Room 306
· Top surface of the television monitor and top surface of the light that was over the bed in Obstetrics Room 305
· Top surface of the cabinet, the wall-hung picture, and the light over the bed in Obstetrics Room 302
· Top surface of the cabinet and the television monitor in Intensive Care Room 2
· Top of the television monitor in Intensive Care Room 3
· Top surface of the cabinet doors in Intensive Care Telemetry Room 5
· Top surfaces of the wall-hung picture and the white/communication board in Medical/Surgical Room 209
· Top surfaces of a wall-hung picture, television monitor, white/communication board
· Top surface of the light over the bed in Medical/Surgical Room 205
· Top surfaces of the closet door and the television monitor in Medical/Surgical Room 219
· Top surfaces of the television monitor in Medical/ Surgical Room 216
· Top surfaces of the arms holding the television monitor in Ambulatory Surgical Unit Rooms 4, 7, and 8
· Top surfaces of the cabinet and the arm that holds the light that extends over the bed in Critical Care (CC) Room 1, on the top surface of the arm that holds the light that extends over the bed in CC Room 2
· Top surface of the cabinets in the Orthopedic Room and in CC Room 4
· This finding was confirmed at the time of the observations by the SP/EPC.

Based on a tour of the facility, policy review, and interview with key personnel on December 14, 2015, it was determined that the facility failed to be in compliance with food service standards and failed to follow facility procedures to assure that outdated food was not available for use for patient consumption.
The Finding includes:

· 2013 Maine Food states in 4-601.11 (A): Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils:
(A) Equipment Food-Contact surfaces shall be clean to sight and touch.
(C) Non-Food-Contact Surfaces of Equipment shall be kept free of an accumulation of dust, dirt, Food residue and other debris.

· Facility Policy Number: 09.6070-IC-5007, Infection Control, Dietary Department; III Procedure: C. Environment; 2. All equipment shall be thoroughly cleaned after each use.

· On December 14, 2015, at approximately 10:15 AM, a meat slicer was observed to have food debris left on the blade and the base.

· This finding was confirmed at the time of the finding by the Food Service Director.

· Facility Policy Number: 05.6780.04: Subject: Par Stock Nourishments. Procedure: 6. Perishable food items will be dated for expiration three days out from opening/preparation. 7. Dietary is responsible for removing outdated items and returning them to the kitchen to be disposed of properly.

· On December 14, 2015, at approximately 1:00 PM, during a tour of the facility with the Safety Specialist/Emergency Preparedness Coordinator (SP/EPC), the following items were found out of compliance with hospital policy:

· An opened bottle of prune juice, dated opened "11/20", an opened bottle of cranberry juice with no label visible indicating when it was opened, and an unlabeled/undated, refillable, plastic, screw capped bottle with a reddish liquid were observed in the Intensive Care Unit patient refrigerator.

· This finding was confirmed at that time and immediately removed from use and disposed of by the SP/EPC.