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Based on review of grievance documentation and interviews with key staff on April 6, 2016, it was determined that the hospital failed to provide the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.


Finding includes:

Northern Maine Medical Center Organization Wide Policy titled 'Patient/Resident/Customer Complaint and Grievance Policy' stated, "A written notice of the facility's determination regarding the grievance will be communicated to the patient or the patient's representative within 7 days."

On April 6, 2016, at approximately 9:00 AM, the documentation of 5 completed grievances was reviewed. There was no documentation that a written notice was provided to the patient in Complaint D.

The Director of Quality Improvement confirmed on April 6, 2016, at approximately 9:45 AM, that there was no written response provided to the patient in Complaint D.

Based on tours of the physical plant which started April 4, 2016 and ended on April 5 2016, it was determined that the facility failed to maintain the physical plant in a manner that assures the safety and well-being of the patients. These tours were conducted with the Maintenance Team Leader.

Finding includes:

During a tour of the physical plant on April 4, 2016, with the Maintenance Team Leader (MTL), from 3:30 PM to 4:30 PM, damage to walls, creating uncleanable surfaces, were observed in Endoscopy in the Women ' s bathroom (four penetrations into the wall to the right of the toilet) and in Bay 1 (eight penetrations into the wall to the left of the stretcher). These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM and on April 5, 2016 from 8:30 AM to 3:30 PM, with the MTL, intravenous (IV) poles with rusty bases (or other parts, as indicated), creating uncleanable services, were observed on the stretcher in Bay 2 of Endoscopy, in the Soiled Utility Room of Cardiopulmonary, on an IV pole in the Stress Test Room of Endoscopy, in the Emergency Department in Patient Exam Room 1 and Patient Exam Room 6, in the Nuclear Medicine Room, in Patient Rooms 305 (on stretcher) and 309 of Oncology, and in Patient Exam Room 3 of the Orthopedics (rusted casters and arms on the IV pole). These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM, with the MTL, step- stools with rusted steps, creating uncleanable surfaces were observed in a section of Endoscopy in the Soiled Utility Room, in Patient Exam Room 2 and in a section of Endoscopy in Patient Exam Room 2, and in Patient Exam Room 2 of Orthopedics. Additionally, a Suction Stand with rusted casters, creating uncleanable surfaces was observed in Operating Room 1. These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM and on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, boxes were stored on the floor, creating a hindrance to cleaning and creating a potential habitat for mold growth were observed in the Storage Room of Cardiopulmonary and in the Blood Bank and Microbiology portions of the Laboratory. These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM and on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, separations between floor tiles, creating uncleanable surfaces were observed in the EKG/EEG Room of Cardiopulmonary, in Patient Room 243 in the bathroom, and in the Sterile Processing Room. These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM, with the MTL, a torn vinyl covering, creating an uncleanable surface was observed on one corner at the foot of the exam table in Patient Exam Room 1 of an area of Endoscopy, on the exam table in Patient Exam Room 2 of the Family Practice Area, and on the right are of the recliner in Patient Exam Room 203 of the Intensive Care Unit. These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, high dust was found in the Emergency Department in Patient Exam Rooms 1, 2, 4, 5, 6, and the Triage Room on the upper horizontal surface of the television (TV) monitors, cabinet doors, in Patient Room 213 on the upper horizontal surface of the TV monitors , over bed light fixture, and trapeze arms, in Patient Room 260 on the upper horizontal surface of the lamp fixture over the bed, In Patient Room 258 on the upper horizontal surface of the bathroom light fixture, in Patient Exam Room 202 on the upper horizontal surface of the trapeze, in Patient Room Exam Room 203 on the upper horizontal surface of the TV monitor, trapeze, and medical gas tower. These findings were confirmed at the time of the findings with the MTL.
During a tour of the physical plant on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, a foam wedge was observed with tears and cracks, creating an uncleanable surface on the exam table of the Bone Densitometry Room. This finding was confirmed at the time of the finding with the MTL.
During a tour of the physical plant on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, crutches with cracked arm pads, creating uncleanable surfaces were observed in the Orthopedic Store Room. This finding was confirmed at the time of the finding with the MTL.
During a tour of the physical plant on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, an IV pole with worn, porous, Velcro-like material, creating an uncleanable surface, was observed in Operating Room 2. This finding was confirmed at the time of the finding with the MTL.
During a tour of the physical plant on April 5, 2016, from 8:30 AM to 3:30 PM, with the MTL, broken wall tiles creating an uncleanable surface were observed to the right of the door of Operating Room 2. This finding was confirmed at the time of the finding with the MTL.

Based on observations made on a tour of the hospital, and interviews with staff conducted on April 4 and 5, 2016, it was determined that not all equipment was being maintained to ensure safety and the quality of its performance.

Finding includes:


During a tour of the physical plant on April 4, 2016, from 3:30 PM to 4:30 PM, with the MTL, in the EKG/EEG Room of Cardiopulmonary, a floor lamp without a sticker indicating that the lamp had been checked for electrical safety was observed. This finding was confirmed at the time of the finding with the Maintenance Team Leader (MTL).
During a tour of the physical plant on April 4, 2016, from 8:30 AM to 3:30 PM, with the MTL, an Olympic Smart (baby) Scale was observed in the Obstetrics Nursery with no sticker indicating it had been checked for patient safety or had been calibrated. This finding was confirmed at the time of the finding with the MTL.
In the MMWR Recommendations and Reports, "Guidelines for Environmental Infection Control in Health-Care Facilities: Recommendations of CDC and the Healthcare Infection Control Advisory Committee (HICPAC)", published on June 6, 2003, stated, that the ice machines need to be cleaned and disinfected on a regular basis and consistent with the manufacturer's instructions for cleaning. In addition the facility needs to ensure that they "Install proper air gaps where the condensate lines meet the waste lines."
During a tour of the Emergency Department at 8:55 AM, on April 6, 2016, the ice machine was observed not to have an air gap installed in its drain line, providing a direct connection to the waste water system and providing potential risk for contamination of the ice provided to patients. This finding was confirmed at the time of the finding with the MTL.