HospitalInspections.org

Based on document reviews and interviews, the hospital failed to provide an acknowledgement letter for two (2) patients and a written notice of its determination regarding a grievance for one (1) of ten (10) sampled patients who filed grievances (Patient #1G, #4G and #8G).

Findings:

The Maine Medical Center "Patient Complaints and Grievances" Policy, dated 1/29/2019, states in part..."3) Addressing Grievances All formal and informal grievances will be investigated to determine if opportunities exist to improve processes and systems related to the issues reported. The following are the steps used to process a grievance within the determined timeframes. The process is managed by the Office of Patient and Guest Relations. a) The grievance will be dated using the date of receipt b) The grievance will be recorded in the Patient Grievance Tracking software c) Assignments for investigation and/or action will be made d) The patient and or patient representative will receive written communication from the organization within seven (7) days of the receipt of the grievance. i) If the investigation is completed within seven (7) days of receipt of the grievance, this written communication shall outline the results and actions taken therein. ii) If the investigation is NOT completed within 7 days of receipt of the grievance, a written communication will be sent acknowledging the receipt of the grievance and notifying the patient or patient's representative that more time is needed to resolve the grievance. Once the grievance is resolved, a written communication shall be sent outlining the results and actions taken during the investigation."

On 8/15/2022 at 1:31 PM, five (5) grievances were reviewed and on 8/18/2022 at 9:00 AM, five (5) additional grievances were reviewed and revealed the following information:

- On 4/14/2022, the hospital received a grievance from Patient #1G. As of 8/24/2022, there was no evidence that the written notice to the patient of its determination outlined the results and actions taken during the investigation.

- On 5/25/2022, the hospital received a grievance from Patient #8G. As of 6/24/2022 there was no evidence of an Acknowledgement Letter being sent within the seven (7) days of receipt of the grievance.

- On 6/15/2022, the hospital received a grievance from Patient #4G. On 6/24/2022 a written acknowledgement letter was sent to the patient but not within the seven (7) days of receipt of the grievance.

On 8/15/2022 at approximately 9:40 AM, the above findings were confirmed with the Director of Patient and Guest Relations.

Based on document reviews and interviews, the hospital failed to ensure a physician's order for a restraint was written for the required timeframe for one (1) of five (5) patients reviewed (Patient #1R).

Findings:

The hospital "Use of Restraints" Policy, last revised 12/2021, states, in part, "If a patient is placed in violent self-destructive restraint or seclusion, the time in restraints starts from the time the intervention is initiated. The following are the age appropriate time limits for the restraint order are as follows: 4 hours for adults ages 18 and older; 2 hours for children and adolescents age 9 - 17; and 1 hour for children under age 9..."

On 8/16/2022 at approximately 1:00 PM, a review of five (5) patients that were restrained was conducted with a Clinical Informatics Nurse.

This review revealed the following:
- Patient #1R is between the ages of nine (9) and seventeen (17); and
- Restraint/Seclusion orders for patient #1R included timeframes intended for adults over 18 years of age, "Frequency: Routine Continuous x 4 hours..."

- On 4/22/2022 at 10:00 PM, Patient #1R's physician ordered a self-destructive restraint order for an adult, which was discontinued on 4/22/2022 at 10:18 PM; and
- On 4/22/2022 at 10:01 PM, Patient #1R's physician ordered a self-destructive restraint order for an adult, which was discontinued on 4/22/2022 at 10:18 PM; and
- On 4/22/2022 at 10:02 PM, Patient #1R's physician ordered seclusion for an adult, which was discontinued on 4/22/2022 at 10:18 PM.

On 8/16/2022 at 1:13 PM, the Clinical Informatics Nurse confirmed these findings.

Based on document reviews, observations and interviews, the hospital failed to ensure that medications were secured and locked during four (4) of eleven (11) medication passes. ( #2, #4, #6, #9).

Findings:

Maine Medical Center's ("MMC") policy titled Administration of Medications, last updated 12/1/2021 states in part, "...All medications will be stored securely between administrations."

MMC's policy titled Storage of Medications in Patient Care Areas and Departments reviewed by the Pharmacy and Therapeutics Committee on 10/2020 and had an Institutional Policy Review on 2/8/2019, states in part, "...These procedures ensure the safe, secure and controlled conditions for the storage of medications...k. Medications are secure..."

- On 8/18/2022, during medication pass #2, a surveyor observed packaged medication tablets that remained on the computer table after the medication pass was complete. When asked about the medication, RN #1 stated, "There are three (3) Tylenol, 325 Milligram ("mg") tablets, they are not mine", and then RN #1 disposed of the medication.

- On 8/18/2022 at approximately 2:55 PM, RN #1 confirmed the above finding.

- On 8/19/2022, during medication pass #4, RN #2 reviewed the patients's chart and noticed it was too early to give the Tylenol brought to the patient's room. While exiting the room, RN #2 was asked if the medication pass was 100% complete. She replied yes and exited the room, leaving the Tylenol on the computer in the patient's room.

- On 8/19/2022 at approximately 9:00 AM, RN #2 confirmed the above finding.

- On 8/19/2022, during medication pass #6, a surveyor observed an item on the computer when entering a patient room for a medication pass. When the pass was complete, the surveyor asked what the item was. The Charge Nurse identified it as the patient's insulin pen and stated, "This should be locked in the medication room."

- On 8/19/2022 at approximately 10:00 AM, the Charge Nurse confirmed the above finding.

- On 8/23/2022, during preparation for medication pass #9, a surveyor observed a medication laying on the counter in the medication room. RN #3 identified the item as Cefepime one (1) Gram ("gm") vial. RN #3 stated, "The medication should have been locked in the patient's bin."

- On 8/23/2022 at approximately 3:15 PM, RN #3 and RN #4 verified the above finding.