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Based on record review, it was determined that the hospital failed to obtain consent to treat for 1 of 28 patient records reviewed. (Record FFF).

The finding includes:

EMMC Interdepartmental Directive No. 20.039, Informed Consent/Procedure Consent Form, states, in part, "Except in an emergency the law requires that health care providers obtain voluntary consent for diagnosis and therapy. The consent must come from the patient, if the patient has capacity, if not, from the patient's legal representative. .. It is the duty of the attending physician or other qualified provider to determine capacity, provide appropriate information, obtain consent, and document the process ..."

Documentation by the Emergency Department Provider, dated January 25, 2017 at 9:00 p.m., indicated when Patient FFF was seen at 8:14 p.m. he/she was alert and oriented to person, place, time, and situation.

The consent to treat form, dated January 25, 2017 at 9:10 p.m., in the patient's record, indicated, on the signature line, "verbal given due to condition".

There was no evidence found that the patient was determined, by the Emergency Department Provider, to have lacked capacity preventing him/her to give written informed consent for treatment.

This finding was confirmed by the Unit Manager on February 2, 2017 at approximately 10:15 AM.

Based on record reviews and interviews, it was determined that the hospital failed to ensure a patient's advance directives were available for staff review to ensure care complied with the patient's desires or that follow up had been completed to determine a patient's wishes for an advance directive for 2 of 28 records reviewed (Record FF and Record HH). In addition, the hospital failed to ensure that the patient's right to formulate and implement an advanced directive for 1 of 28 patient records, (Record RR).

The finding includes:

1. Documentation in Record FF indicated the patient had an advance directive (a living will and a medical power of attorney) and a copy of the advance directive had been placed in the patient's record.

On February 1, 2017 at 8:39 AM, a review of the patient's record, by the surveyor with the Registered Nurse (RN) - Director of Nursing Systems, revealed no copy of the advance directive in the patient's paper or electronic record.

On February 1, 2017 at 10:01 AM, the Nurse Manager of Grant 4 confirmed that they did not have a copy of the patient's advance directive.

The hospital staff and practitioners, who provide care to this patient, are required to comply with the patient's advance directive and without a copy of the advance directive these providers may not know the patient's wishes.

2. Documentation in Record HH indicated that the staff was unable to assess if the patient had an advance directive.

As of February 1, 2017 at 9:37 AM, 14 days after admission, the surveyor and the RN - Director of Nursing Systems were unable to find any evidence in the patient's record that indicated that any follow up had been completed with the patient or his/her family regarding advance directives.

On February 2, 2017 at 10:17 AM, the surveyor again confirmed with the RN - Director of Nursing Systems that there was no further evidence regarding this patient's advance directives.

3. On January 30, 2017 at approximately 11:10 AM, Patient RR complained to the surveyor that he/she had requested and been provided advance directive forms during admission on January 25, 2017. Patient RR stated that the forms were completed and he/she had been requesting staff to take them for three days.

A review of Patient Record RR found that the initial admission documentation, conducted by the Registered Nurse on January 25, 2017, indicated that the patient did not have an advance directive and it was also documented that no advance directive information was provided to the patient.

This finding was confirmed, by the Nurse Manager, on January 30, 2017 at approximately 2:15 PM.

Based on observations, document reviews, and interviews, it was determined that the facility failed to maintain patient care areas in a manner that minimized the risk of infection transmission and cross contamination in 2 of 4 buildings (main campus and Union Street Mall Healthcare).

The finding includes:

1. On January 30, 2017 from 9:45 AM to 12:00 PM, during a tour of the main campus, with the Facilities' Administrator the following was observed in the Grant 8 unit:

a. The finish on all of the wooden window sills was worn in all patients' rooms.

b. The finish on the wooden bumper rails was worn in Room 855.

c. There was a broken tile next to the toilet in the bathroom, a loose hanging cove base (flooring) in the bathroom near the bath, and an unfinished wall patch to the left upon entry to the room in Room 856/857.

d. There were damaged cove bases by the tub and the toilet in Room 859.

e. The finish was worn on the desk and there was a chip on the top edge of the desk in Room 860/861.

f. There was unsealed concrete near the top of the window frame in Room 860/861.

g. There was a broken section of cove base near the far left corner of the room in Room 860/861.

h. There was tape residue on the wall in Room 860/861.

i. There was an unsealed seam on the cover of a green vinyl floor mat In the play room.

j. There was a damaged lower edge on the wall in the courtyard.

k. There was a peeling cove base in the shower area in Room 868.

l. The veneer was peeling off the bedside table in Room 868.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed, with the Facilities' Administrator, at the time of the observations.

2. On January 30, 2017 between 9:45 AM and 12:00 PM, in the family kitchen of the Grant 8 unit, the surveyor observed that there was no functional air gap in the drain line of the ice machine plumbing which created a potential for waste water back up into the ice machine. This finding was confirmed, at the time of the observation, with the Facilities' Administrator.

3. On January 30, 2017, between 12:30 PM and 1:30 PM, in the kitchen, the surveyor observed six wet stacked steam table pans, which created an unsanitary environment conducive for bacterial growth. The Director of Food and Nutrition was present during this observation.

4. On January 30, 2017, from 12:30 PM to 3:30 PM, during a tour of the main campus with the Environmental Health and Hospitality Manager, the following was observed in the Emergency Department (ED), Grant Intensive Care Unit (GICU), or the Critical Care Unit (CCU):

a. There was a significant accumulation of dust in the following locations: on the top of the door frame in Room 17 of the ED; on the top of the closet doors in Room 131 of GICU and in Room 157 of the GICU; on the top edge of the television monitor in Room 131 of GICU; on the top of the wall mounted lamp in Room 138 of GICU, in Room 145 of GICU, in Room 155 of the CCU, and in Room 154 of the CCU; on the wall mounted headboard in Room 162 of the CCU, in Room 152 of the CCU, and in Room 154 of the CCU.

b. The was broken flooring under the compacter in the soiled utility room of the ED.

c. There was a build-up of debris on the base of the laundry hamper in the following locations: in Room 3 in the ED; in Room 6 in the ED; in Room Critical 3 in the ED; and in Room 157 of the CCU.

d. The foot pedal to open the lid of the laundry cart, located in Room 6 of the ED, was not functioning necessitating the use of hands to open the cart's lid. This non-functioning pedal created a potential infection control risk.

e. The edges of the floor mat, located in the Triage Room in the ED, were torn.

f. There were scratches on the wooden bumper rails located in Room 18 in the ED.

g. There was no functional air gap in the drain line of the ice machine plumbing in the following locations: the clean utility room of the ED and the clean utility room of GICU. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

h. There was a pressure infuser bag, located in the clean utility room of the ED, was hanging from a shelf of clean patient supplies with the inflating bulb hanging into the trash can. This location of the pressure infuser bag created a potential for contamination.

i. There was a bag of uncleaned empty returnable bottles and cans was located in the clean utility room of the ED between a shelf of clean supplies and a patient blanket warmer.

j. There were cracks in the cove base (flooring) in the following areas: in Room 20 of the ED; in Room 144 of the GICU; in Room 145 of the GICU; and in Room 154 of the CCU.

k. The cove base was peeling away from the wall in Room 152 of the CCU.

l. The wooden window seal finish was worn in the following locations: the Psychiatric Area Waiting Room of the ED; in Room 144 of GICU; and in Room 145 of GICU.

m. There was unsealed concrete adjacent to the window frame in the Psychiatric Area Waiting Room of the ED.

n. There were taped areas on the bottom of the privacy screen in Room 144 of the GICU.

o. The casters of an intravenous pole, located in the clean utility room of the GICU, were rusty.

p. There were stains along the bottom eighteen inches of a headboard located in Room 152 of the CCU.

q. The veneer was damaged on the headboard located in Room 152 of the CCU.

r. There were stains on the floor around the base of the toilet in Room 152 of the CCU.

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

5. On January 30, 2017 from 1:00 PM to 3:30 PM, on a tour of the facility the following was observed:

ON THE PENOBSCOT UNIT:

a. There was a significant accumulation of dust in the following areas: by the entrance door of Rooms 698 and 792; on the top of the window frame in Room 671 and Room 685.

b. There was a tear in the seat in the blue chair in Room 692

c. The finish on the wooden chair was worn in Room 692

The above findings created a surface which could not be easily cleaned and sanitized.

These findings were confirmed, at the time of the observations, with the Facilities' Administrator.

GRANT 4 INPATIENT UNIT:

a. There was aged window sealant in Rooms 513 and 523

b. The finish was worn on the wooden chair in Rooms 513 and 534

c. There were gouges in the wall by the sink in Room 516

d. The varnish was worn around the window frame in Room 516 and 517 and bumper guards in Rooms 516 and 534

e. There were wall mounted cork board in Rooms 516, 517, 523, and 532

f. There was velcro tape on the window frame in Room 532

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Assistant Nurse Manager.

GRANT 5 INPATIENT UNIT:

a. There was aged window sealant in Rooms 513 and 523

b. The finish was worn on the wooden chair in Rooms 513 and 534

c. There were gouges in the wall by the sink in Room 516

d. The varnish was worn around the window frame in Room 516 and 517 and bumper guards in Room 516 534

e. There was a wall mounted cork board near the bathroom in Room 516, 517, 523, and 532

f. There was velcro tape on the window frame in Room 532

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with Charge Nurse or Nurse Manager.

GRANT 6 INPATIENT UNIT:

a. The end of the pull cord for the call light was approximately three to four inches long in Room 623. This location would make it difficult to reach by anyone who may have fallen to the floor; thus making the rending the call system ineffective.

b. There was a significant accumulation of dust in the following areas: on the window tops in Room 603 and on the window sill in Room 608, 617, and 626

c. There was aged window sealant in the following areas: Rooms 600, 604, 609, and 612

d. There was a wall mounted corkboard in Rooms 603 and 604

e. There was damage to the base of the wall in Room 604

f. There was peeling flooring near the toilet in Room 608

g. There was a gouge in the wall near the electrical outlet in Room 609 and near the sink in Room 617

h. There were cracks in the floor near the wall where the television was mounted in Room 621 and in the bathroom in Room 626

i. There was peeling paint in 623

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Nurse Manager, Assistant Nurse Manager, or the Finishing Supervisor.

LABOR AND DELIVERY:

There were gouges in the wall in Room 568, 570, and 580 creating created a surface which could not be easily cleaned and sanitized.

The above finding created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with Charge Nurse or the Finishing Supervisor.

KELLY 3 INPATIENT UNIT:

a. There was a significant accumulation of dust in Room 385

b. There was a large crack int he wall in the K 3 Common/Reading Area

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the the Environmental Health and Hospitality Manager.

6. On January 31, 2017, from 6:30 AM to 4:00 PM, on a tour of the main campus with the Environmental Health and Hospitality Manager the following was observed:

IN THE CARDIAC CATHETERIZATION LAB (CCL) AREA:

a. There was rust on the floor and the bottom of the door frame. This created a surface which could not be easily cleaned and sanitized.

b. There were multiple holes in the flooring in the Holding Room

c. The veneer was missing on a cabinet in Bay 3

d. The wall, behind the trash can, was damaged in Bay 2 and Bay 3

e. There were seven times were taped to the wall in CCL 1

f. There were multiple items were taped to the walls in CCL 2

The above findings created a surface which could not be easily cleaned and sanitized.

These findings in the CCL area were confirmed, with the CCL Manager and the Environmental Health and Hospitality Manager, at the time of the observations.

IN THERE ELECTROPHYSIOLOGY PROCEDURE (EP) AREA:

a. There were rusty casters on the trash bag stand

b. There were five stained ceiling tiles indicating water leakage in Room 2. These stained tiles created a habitat for mold growth.

c. There were paper items taped to the walls

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

IN THE RADIOLOGY AREA, IN THE ULTRASOUND AREA, THE NUCLEAR MEDICINE AREA, AND THE VASCULAR LAB:

a. The cove base was peeling off the wall near the far right corner of X-Ray Room 6

b. There was wall damage in the Radiology Interventional Restroom

c. There was cracked cove base in Ultrasound Room 4

d. There was a puncture in the vinyl covering of the stretcher mattress pad in Ultrasound Room 3

e. There were tears in the vinyl covering of the stretcher mattress pad in Ultrasound Room 1

f. There was peeling paint on the lower border of the wall In Ultrasound Room 1

g. There were four perforations into the vinyl covering in the Nuclear Medicine Preparatory Room

h. The end of pull cord for the call light was approximately two feet above the floor in Vascular Lab Bathroom 2 and in the Vascular Lab Reception Bathroom. These locations would make it difficult to reach by anyone who may have fallen to the floor; thus making the rending the call system ineffective.

i. There were rough damaged edges on the wooden benches in the Vascular Lab Exam Rooms 5, 6, and 10.

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

IN THE PHARMACY AND OUTPATIENT SURGICAL CARE (OSC) AREA:

a. The cove base under the tube transport system was in need of repair in the Pharmacy. This created a surface which could not be easily cleaned and sanitized.

b. There was no functional air gap between the drain line and the wastewater plumbing of the ice machine in the Outpatient Surgical Care Recovery Kitchenette. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

c. There was a stained ceiling tile indicating water leakage in the OSC Housekeeping closet and creating an environment for mold growth. This stained tile created a habitat for mold growth.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

IN THE OPERATING ROOM (OR) AREA:

a. There were items fixed to the wall with tape in Rooms 1, 2, 7, 11, and 12.

b. There was bubbling and flaking paint on a slide out board in Room 6

c. There were wall mounted speakers with fabric or foam faces, in Room 1

d. There were two stained ceiling tile indicating water leakage in the back hallway of the OR area. These stained tiles created a habitat for mold growth.

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

ON THE MERRIT 3 INPATIENT UNIT:

a. There were wall mounted corkboards in all patient rooms

b. There was a significant accumulation of dust in the following locations: on the top of the closet doors in Room 303, Room 316, Room 317, Room 321, Room 325, Room 326, Room 327, Room 330, and Room 331; and on top of the bathroom door in Room 322

c. There was no functional air gap was observed between the drain line and the wastewater plumbing of the ice machine, creating a potential for the backflow of wastewater into the ice machine. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

d. There was flaking/peeling paint on the window sill in Room 312

e. There were cracks in the cove base in Room 316, Room 321, and Room 322

f. There was a container of suctioned bodily fluids in Room 317. In an interview with the patient's relative, he/she indicated the patient's naso-gastric tube had been removed three days prior and the nurse had indicated she would return to remove the container but never did.

g. There was a build-up of debris on the base of the laundry cart in Room 326

h. There was a rough unsealed surface in the shower in Room 327

i. There was a delaminating area on the closet in Room 330

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

ON THE KELLY 3 INPATIENT UNIT

a. There was gllue residue and foam on the window frame in Room 378

b. There was six stained ceiling tile indicating water leakage in the Room 378. These stained tiles created a habitat for mold growth.

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, by Registered Nurse (RN) from the unit and the Environmental Health and Hospitality Manager.

ON THE KELLY 4 INPATIENT UNIT

a. There was no functional air gap was observed between the drain line and the wastewater plumbing of the ice machine, creating a potential for the backflow of wastewater into the ice machine. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

b. There were six stained ceiling tile indicating water leakage in the Room 455. These stained tiles created a habitat for mold growth.

c. There were wall mounted corkboards in all patient rooms

d. The cove base was missing in Room 438

e. There was torn paper covered insulation around the radiator heat pipes coming from the floor in Room 440, Room 444, Room 447, Room 455, Room 456

f. There was glue residue and foam on the window frame in Room 444, Room 447, Room 455

g. There was a significant accumulation of dust in the following areas: on top of the wall-mounted lamp in Room 444,

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observation, with the Assistant Nurse Manager and the Environmental Health and Hospitality Manager.

ON THE KELLY 5 INPATIENT AREA:

a. The finish on the wooden radiator cabinets was worn in all patient rooms

b. There was a significant accumulation of dust in the following locations: on the closet doors in Rooms 558, 564, and 567

c. There was peeling cove base in Room 558

d. There was a damaged and splintered area on the bottom of the wall-mounted headboard in Room 559

e. There was torn paper covered insulation around the radiator heat pipes coming from the floor in Rooms 559, 564, and 567

f. There was a damaged and splintered wooden wall bumper in Room 567

g. There was no functional air gap was observed between the drain line and the wastewater plumbing of the ice machine, creating a potential for the backflow of wastewater into the ice machine. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

h. There was glue residue and foam on the window frame in Room 564

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed, at the time of the observations, by both a nurse from the unit and the Environmental Health and Hospitality Manager.

ON THE PHILLIPS OLIVER INPATIENT UNIT:

a. There was no functional air gap was observed between the drain line and the wastewater plumbing of the ice machine, creating a potential for the backflow of wastewater into the ice machine. The lack of a functional air gap created the potential for waste water to back up into the ice machine.

b. There were wall mounted corkboards in all patient rooms in many patient rooms

c. There was a significant accumulation of dust in the following areas: on the top of the closet door in Room 388, Room 390, Room 395, Room 398

d. There was a build-up of debris on the base of the laundry cart in Room 390

The above findings created a surface which could not be easily cleaned and sanitized.

The above findings were confirmed at the time of the observations, with a Registered Nurse on the unit and the Environmental Health and Hospitality Manager.

7. On February 1, 2017 between 8:30 AM and 12:30 PM, on a tour of the Union Street Health Care Mall with the Environmental Health and Hospitality Manager, the following was observed:

a. In Family Medicine Procedure Room A, a gouge was observed in the wall, creating a surface which cannot be easily cleaned and sanitized.

b. In the Prenatal Testing area, wall-mounted cork boards which provide a surface which cannot be easily cleaned and sanitized were observed in all patient care rooms. Additionally in Rooms 11, 31 and 32, peeling and chipped laminate, creating a surface which cannot be easily cleaned and sanitized was observed on the bases of the sink cabinets. In Room 35, two stained ceiling tiles were observed, indicating water leakage and creating a habitat for mold growth. In rooms 9 and 10, a significant accumulation of dust was observed, indicating an unclean and un-sanitized surface.

c. In Diabetes and Endocrine Medicine, a tear in the vinyl covering of the exam table was observed In Rooms 4 and in a First Floor Exam Room, creating surfaces which cannot be easily cleaned and sanitized. Additionally in Exam Room 6 (first floor), rust stains, creating surfaces which cannot be easily cleaned and sanitized were observed on 2 floor tiles.

d. In Exam room 1 of Allergy and Immunology, a gouge was observed in the wall, creating a surface which cannot be easily cleaned and sanitized.

e. In Eastern Maine Otolaryngology, in Exam Room 3, peeling laminate, creating a surface which cannot be easily cleaned and sanitized was observed on the base of the desk. In Exam Room 2, a rusted rim, creating a surface which cannot be easily cleaned and sanitized, was observed on the biomedical waste can. In Exam Room 5, a gouge was observed in the corner wall, creating a surface which cannot be easily cleaned and sanitized.

f. In Retina Associates of Maine, in Exam Room 2, paint flaking off the wall near the sink and a gouge on the back wall were observed, creating surfaces which cannot be easily cleaned and sanitized.

g. In Eastern Maine Rehabilitation, in Room 5, cracks in the vinyl covering, creating a surface which cannot be easily cleaned and sanitized, were observed on the exam table. Additionally, gouges were observed in the back wall creating a surface which cannot be easily cleaned and sanitized. In Room 15 a wall-mounted cork board was observed in the room, which provides a surface which cannot be easily cleaned and sanitized. In Room 12, gouges and pin holes in the wall, creating a surface which cannot be easily cleaned and sanitized, were observed on the walls. In Room 10, tape and pin holes were observed on the walls, creating surfaces which cannot be easily cleaned and sanitized

h. In the Anticoagulation Unit, gouges in the wall, creating a surface which cannot be easily cleaned and sanitized, were observed on the corner wall.

i. In Eastern Maine Medical Center Orthopedics, Exam Rooms 5, 6, 7, 8, and 9, wall-mounted cork boards were observed, providing surfaces which cannot be easily cleaned and sanitized.

j. In the Outpatient Imaging Center Pain Clinic, In Exam Room 2, a large adhesive board, that provided surfaces which cannot be easily cleaned and sanitized.

k. In the Computed Tomography (CT) and Imaging Area, in Pain Procedure Room 2, a chipped door, creating a surface which cannot be easily cleaned and sanitized, was observed by the dry storage area. In Procedure Room 1, A four foot long gouge, creating a surface which cannot be easily cleaned and sanitized, was observed in the wall.

l. In X-Ray and Imaging, in Exam Room 4, gouges into the wall, creating surfaces which cannot be easily cleaned and sanitized, were observed on the back wall and under the window by the staff area.. Additionally tape was observed on the walls, creating a surface which cannot be easily cleaned and sanitized. In Exam Room 2, gouges and tape were observed on the walls, creating a surface which cannot be easily cleaned and sanitized. In Exam Room 1, dings and cracks on the corner wall were observed, creating a surface which cannot be easily cleaned and sanitized.

All findings in the Union Street Health Care Mall were confirmed, at the time of the observations, with the Environmental Health and Hospitality Manager.

Based on record reviews and interview, it was determined that the hospital failed to have evidence of the time a restraint was discontinued for 1 of 5 patient records review of patients who were restrained (Record HH). This failure resulted in the inability to determine if the restraint was discontinued at the earliest possible time.

The finding includes:

1. Documentation in Record HH indicated that a vest restraint was ordered on January 19, 2017 at 11:54 AM. Documentation in the record indicated that the vest restraint was initiated at 1:00 PM after alternative interventions had been attempted and were ineffective. Documentation, at 2:49 PM, by a Registered Nurse (RN) indicated the Charge Nurse had spoken to a physician about the patient's plan of care and safety and the plan included a 1:1 sitter and to discontinue the vest restraint. However, there was no documentation as to when the vest restraint was actually discontinued; therefore it could not be determined if the restraint was discontinued at the earliest possible time.

On February 1, 2017 at 9:45 AM, the surveyor confirmed this finding with the RN - Director of Nursing Systems.

On February 2, 2017 at 10:22 AM, the surveyor again confirmed that no further information was found regarding the discontinuation of this restraint with the RN - Director of Nursing Systems.

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Based on record review and interview with staff, it was determined that the hospital failed to document physician assessments and two hour visual safety checks and CSM (Circulation, Sensation, Motion) of each restrained extremity and monitor the patient for safety and comfort for 1 of 1 restrained patient record.

The finding includes:

1. EMMC Patient Care Directive No. 06.001 Non-Violent or Non-Self Destructive (Medical Surgical) Restraint Management, states in part, "IV. Procedure B. Restraint Orders 5. If the RN performs the initial assessment, a face to face reassessment by the provider must occur by the 24th hour and a new order written as appropriate"

A review of Patient Record XX, conducted on February 2, 2017 at approximately 10:45 AM, found that a physician order for restraint was entered by the registered nurse on January 29, 2017 at 11:51 AM. The record failed to contain required documentation of required physician assessments. A further review of this patient record found that physician orders for restraint were entered on January 30, and 31, 2017 and also on February 2, and 3, 2017. The record failed to contain any physician documentation of patient assessments for each orders for restraint.

2. EMMC Patient Care Directive No. 06.001 Non-Violent or Non-Self Destructive (Medical Surgical) Restraint Management, state in part, "D. Monitoring of Patients in Restraints 6. Physical restraints are released every 2 hours for at least 15 minutes for assessment, ADL's, range of motion and assessment for release (by trained RN)."

A review of Patient Record XX fails to contain documentation of the required release of restraint and range of motion every two hours for the following dates and times:

January 31, 2017- 5:37 AM to 8:15 AM;
January 31, 2017- 10:15 AM to 12:46 PM;
February 1, 2017- 5:00 AM to 7:28 AM; and
February 1, 2017- 9:09 AM to 11:25 AM

Based on record reviews and interviews, it was determined the hospital failed to ensure that a nursing care plan was developed for identified issues for 3 of 30 records reviewed (Record FF, Record HH, and Record PP).

The finding includes:

1. Record FF contained documentation in the nurses' notes, dated January 30, 2017 and January 31, 2017, that indicated the patient had a scabbed area on his/her left heel. A dynamic group, which is part of the electronic record that indicates that there has been documentation in a certain area, was created on January 30, 2017. This created dynamic group indicated the patient had multiple dried scabbed areas on both of his/her legs that were black in color and they were left open to the air.

A physician's note, dated January 31, 2017 at 11:25 AM, indicated the patient had a chronic left heel ulcer that was not infected and was probably due to peripheral vascular disease.

The record review, on February 1, 2017, revealed there was no evidence that a nursing plan of care had been developed for skin integrity for this patient. On February 1, 2017 between 8:41 AM and 8:49 AM, the surveyor confirmed, with the Registered Nurse (RN) - Director of Nursing Systems, that a nursing plan of care related to skin integrity had been developed for this patient. The Director indicated that she would have expected to have seen a nursing plan of care.

2. Record HH indicated that the patient received insulin, on an as need basis, on eleven occasions between January 20, 2017 and January 31, 2017 because of elevated blood sugars. A review of the patient's history and physical, completed on admission, indicated that the physician was unable to determine the patient's current medication and reviewed the last available history and physical dated December 16, 2016. The last available history and physical did not indicate that the patient had not been taking insulin at home.

On February 1, 2017 at 10:18 AM, the surveyor and the RN - Director of Nursing Systems reviewed the patient's current nursing plan of care. The nursing plan of care did not address the need for insulin administration as the plan of care for "alteration in metabolic status" had not been initiated. At 10:20 AM, the RN - Director of Nursing Systems indicated that she would have expected the need for insulin administration to be addressed on the nursing care plan.

3. Documentation in Record PP, dated January 26, 2017, indicated the patient's buttocks were red and blanchable and Calmoseptine was ordered. Calmoseptine ointment is an analgesic, antiseptic, antipruritic, and skin protectant combination ointment.

Documentation, dated January 27, 2017, indicated the patient's rectal area was slightly red.

The patient's medication administration record indicated that from January 27, 2017 through February 1, 2017 at 8:19 AM. Calmoseptine was applied to the patient's buttocks eleven times.

On February 1, 2017 at 3:03 PM, the surveyor and the RN - Director of Nursing Systems reviewed the patient's nursing plan of care. The nursing plan of care for skin integrity identified that the patient had impaired skin integrity; however, the impaired skin integrity was related to a surgical procedure and did not identify that the patient had skin integrity issues on his/her buttocks and rectal area. The surveyor confirmed this finding, at the time of the review, with the RN - Director of Nursing Systems. She indicated that she would have expected that the nursing plan of care would have addressed skin integrity other than the patient's surgical incisions.

Based on record reviews, observation, and interview, it was determined the hospital failed to ensure a medical care was accurate for 1 of 30 records reviewed (Record FF).

The finding includes:

Record FF contained documentation in the nurses' notes, dated January 30, 2017 and January 31, 2017, that indicated the patient had a scabbed area on his/her left heel.

A physician's note, dated January 31, 2017 at 11:25 AM, indicated the patient had a chronic left heel ulcer that was not infected and was probably due to peripheral vascular disease.

On February 1, 2017 at 11:15 AM, the surveyor interviewed the Registered Nurse (RN) assigned to the patient. She indicated that the patient did not have an area on his/her left heel and the area was on the patient's left Achilles area (area on the back of the foot above the heel).

On February 1, 2017 at 11:21 AM, the RN and the surveyor observed the patient's left heel. The surveyor observed a dried black area, that was just slightly smaller than a dime, on the patient's left Achilles area. There was no area on the patient's left heel.

On February 1, 2017 at 9:30 PM, a RN documented that the patient's "left heel stasis ulcer" was benign.

On February 2, 2017 at 10:02 AM, the surveyor again discussed and verified, with the Director of Nursing Systems, that the record contained inaccurate information as the area was not located on the patient's left heel.

Based on review of medical records and facility policy and procedures and interviews, it was determined the hospital failed to document the patient's response to medications and progress related to identified problems for 3 of 30 records reviewed (Record FF, Record PP, and Record RR).

The finding includes:

1. Documentation in Record FF indicated the patient received the medication Ropinirole, which was ordered on an as needed basis (prn) for restlessness, on January 29, 2017 at 11:46 PM, January 30, 2017 at 9:51 AM, and on January 31, 2017 at 9:07 AM and 7:58 PM. There was no documentation in the record to indicate the patient's response to the administration of this medication on these four occasions.

The hospital's "Medication Administration and Management" policy and procedure, dated October 25, 2016, indicated all prn medications would have a documented response on the medication administration record.

On February 1, 2017 at 9:02 AM, the surveyor confirmed this finding with the Registered Nurse (RN) - Director of Nursing Systems.

2. Documentation in Record PP, dated January 26, 2017, indicated the patient's buttocks were red and blanchable and Calmoseptine was ordered. Calmoseptine ointment is an analgesic, antiseptic, antipruritic, and skin protectant combination ointment.

Documentation, dated January 27, 2017, indicated the patient's rectal area was slightly red.

Between January 27, 2017 and February 1, 2017, at the time of the record review, there was no further documentation regarding the patient's skin integrity on his/her buttocks or rectal area.

The patient's medication administration record indicated that from January 27, 2017 through February 1, 2017 at 8:19 AM. Calmoseptine was applied to the patient's buttocks eleven times.

The medical record did not contain documentation regarding patient's skin integrity since January 27, 2017; therefore did not contain information regarding the patient's response to the Calmoseptine ointment.

On February 1, 2017 at 3:02 PM, the surveyor confirmed, with the RN - Director of Nursing Systems, that there was no documentation after January 27, 2016.

3. The history and physical, dated January 25, 2016, in Record RR indicated the patient had a healing stage three (3) sacral decubitus ulcer that had been healing nicely with aggressive care at home, and there was no erythema (abnormal redness), drainage, odor, or any other evidence of infection.

Between January 25, 2017 and February 2, 2017 at 11:10 AM, the following documentation was found in the record regarding the patient's ulcer:

- The nurses' notes, dated January 25, 2017 at 12:15 AM indicated the patient had dressing to his/her sacrum that was intact and there was a quarter centimeter circular looking wound with pale edges that was healing.

- The nurses's notes, dated January 25, 2017 at 5:50 PM indicated the patient had a healing stage 3 ulcer on his/her coccyx.

- The nurses' notes, dated January 27, 2017 at 11:44 PM indicated the patient had been admitted with a Stage 3 ulcer on his/her coccyx.

- The integumentary assessment of the record, dated January 31, 2017 at 8:45 AM and 11:00 PM and on February 1, 2017 at 11:00 PM, indicated the patient had a healing pressure ulcer on his/her coccyx.

- The nurses' notes, dated February 1, 2017 at 5:51 PM indicated the patient had a pressure ulcer on his/her coccyx.

- The nurses' notes, dated February 2, 2017 at 11:10 AM, indicated the patient had a healing sacral decubitus ulcer.

The nursing plan of care indicated that patient had impaired skin integrity, had an open wound, a complete head to toe skin assessment at a minimum every shift and skin assessment, document findings and report as necessary.

The hospital's "Skin and Pressure Ulcer Assessment and Management" policy and procedure, dated April 20, 2015, indicated the following:

- A full head to toe assessment skin integrity assessment will be completed and documented upon admission, transfer, every shift and with change of caregiver.

- Assess and document the wound/pressure ulcer's length, width, and depth, and if tunneling or undermining is present with with dressing changes or daily if no dressing.

- Stage only pressure ulcers without reverse staging

- Pressure ulcer documentation would include the following; location/position; color/description of wound bed; appearance of peri-wound skin; presence of any odor or irrigation; exudate if applicable, and pressure ulcer stage.

The record did not contain documentation as required by hospital policy and procedure and assessments that would describe the progress of this ulcer.

On February 2, 2017 at 11:44 AM, the surveyor confirmed the lack of documention in the record with the RN - Director of Nursing Services. She indicated that she would have expected to see documentation that included measurements of the ulcer in the record.

4. Documentation, dated January 30, 2017 at 2:50 PM, in Record RR indicated the patent had a blister on his/her left ankle and Mepilex was applied to the area. It was noted that there was no indication that this area had been present on admission to the hospital five days prior.

Between January 30, 2017 after 2:50 PM and February 2, 2017 at 11:44 AM, the following documentation was found in the record regarding the patient's left ankle:

- On January 28, 2017 from 7:00 AM to 5:00 PM, it was noted, in the morning, the patient had a blister on his/her left outer ankle and Mepilex was applied.

- On January 28, 2017 at 8:00 AM, the patient had reddened areas on his/her outer ankles of the left foot and a blister was noted.

- On January 29, 2017 at 7:00 AM, the patient had a blister on his/her outer left ankle.

- On January 30, 2017 at 2:50 PM, the patient had a blister on his/her left ankle.

The record did not contain documentation as required by hospital policy and procedure, and assessment that described the progress of the blister on the patient's ankle.

On February 2, 2017 at 11:44 AM, the surveyor confirmed the lack of documention in the record with the RN - Director of Nursing Services. She indicated that she would have expected to see documentation.

Based on record review and interviews with staff, it was determined that the hospital failed to ensure that physician progress notes were legible in 2 of 28 medical records reviewed.

The finding includes:

1. Patient Record QQ contained handwritten physician progress notes, dated January 28, 2017 and January 29, 2017, which were illegible.

This finding was confirmed, by the Interim Assistant Nurse Manager, on February 1, 2017 at approximately 1:35 PM who stated, "Yes, I can't read them. It is a problem."

2. Patient Record DDD contained handwritten physician progress notes, dated January 26, 2017; January 27, 2017; January 28, 2017; January 29, 2017; and January 30, 2017, which were illegible.

This finding was confirmed, by the Interim Assistant Nurse Manager, on February 2, 2017 at approximately 10:45 AM.

Based on observation, document review, and interviews, it was determined that the physical plant and overall hospital environment was not maintained in a manner that the safety and well-being of patients was assured in 1 of 4 buildings (main campus).

The finding includes:

1. The Patient Care Directive "Maintenance of Defibrillators, Emergency Drug Trays and Code Blue Carts" states: "Defibrillator/AED check ... Maintain a log of the daily checks ..."

On January 30, 2017, during a tour of the Emergency Department between 10:00 AM and 12:00 PM, the following was found:

a. The front hallway code cart log failed to contain documentation that the daily checks were conducted on January 17, 2017.

b. The pediatric code cart log failed to contain documentation that the daily checks were conducted on December 1, 9, 13, 20, 28 and 29, 2016 and January 3, 6, and 15, 2017.

c. The Trauma code cart log failed to contain documentation that the daily checks were conducted on September 2, 5, 17 and 24, 2016.

These findings were confirmed with the Emergency Department Nurse Manager and the Emergency Department Director of Nursing at the time of the discovery.

On January 31, 2017 at approximately 3:30 PM, additional code cart log documentation was provided by the Emergency Department Director of Nursing. The following was found:

- The Trauma code cart log failed to contain documentation that the daily checks were conducted on November 9, 11, and 28, 2016 and December 5, 27 and 28, 2016.

- The Critical Care code cart log failed to contain documentation that the daily checks were conducted on November 9, 12, 16, 22, and 26, 2016 and December 1, 2016.

- The Pediatric Care code cart log failed to contain documentation that the daily checks were conducted on November 2, 8, 9, 12, 16, 22 and 26, 2016, December 8,9, 28 and 29, 2016 and January 1, 3, 6, and 15, 2017.

- The Front Hall code cart log failed to contain documentation that the daily checks were conducted on November 8, 9, 12, 16, 22, and 26, 2016 and January 17, 2017.

- The Back Hall code cart log failed to contain documentation that the daily checks were conducted on November 9, 2016 and December 1, 9, 13, 20, 28, and 29, 2016.

The Emergency Department Director of Nursing confirmed, on January 31, 2017 at approximately 3:30 PM, that the above findings were accurate, and that a corrective action plan had been initiated.

2. On January 30, 2017, from 12:30 PM to 3:30 PM, during a tour of the facility with the Environmental Health and Hospitality Manager, the following was observed:

a. In Phillips-Oliver Room 388, a fully opening window, allowing patient egress and thus being a potential safety hazard, was observed near the B bed. This finding was confirmed at the time of the observations with the Environmental Health and Hospitality Manager.

b. In Kelley (K) Room 377, a fully opening window was observed, allowing patient egress and thus being a potential safety hazard. This finding was confirmed at the time of the observations with the Environmental Health and Hospitality Manager.

3. On January 30, 2017 from 1:00 PM to 3:30 PM, on a tour of the facility with the Facilities Administrator the following was observed: In the Common Area near Room 525, a fully opening window was observed, allowing patient egress and thus being a potential safety hazard. This finding was confirmed at the time of the observations with the Facilities Administrator.

a. In Room Kelley (K) 385, two fully opening windows were observed, allowing patient egress and thus creating a potential safety hazard. This finding was confirmed at the time of the observation with the Environmental Health and Hospitality Manager.

b. In Room K 384, a fully opening window was observed, allowing patient egress and thus creating a potential safety hazard. This finding was confirmed at the time of the observations with the Environmental Health and Hospitality Manager.

c. In the K 3 Common/Reading Area, a fully opening window was observed, allowing patient egress and thus creating a potential safety hazard. This finding was confirmed at the time of the observation with the Environmental Health and Hospitality Manager.

Based upon on-site observations, interviews, and document reviews conducted by Life Safety Code surveyors, it was determined that Eastern Maine Medical Center was not in full compliance with 42 CFR §482.41(b), the Life Safety Code.

Please see the Life Safety violations cited on the Centers for Medicare and Medicaid Services (CMS) form 2567 dated February 1, 2017, for the Maine State Fire Marshal's Office Life Safety Code survey.