HospitalInspections.org

Based on record review and interview with key personnel on February 10, 2015, it was determined that the facility failed to assure that all patient's received a notice of patient rights in advance of furnished care.
The finding includes:

1. The medical record of Patient QQQ lacked evidence that the patietnt was informed of his/her patient rights prior to care being furnished to him/her.

2. The above finding was confirmed by the Vice President of Nursing on February 11, 2015 at approximately 11:25 AM.

Based on observation and interview with key personnel on February 9, 2015, it was determined that the facility failed to assure that the clinical records of patients were maintained in a manner to ensure confidentiality.

The finding includes:

1. During a tour of the Single Stay unit on February 9, 2015, nine (9) patient records were observed in a chart rack in the hallway, around the corner of the nursing station, away from continuous view of staff. These records were unsecured and were noted to have patient names on all nine (9) of the charts; these records were clearly visible, available and accessible to anyone passing by in the hallway.

2. This finding was confirmed by the Clinical Coordinator and the Vice President of Nursing on February 9, 2015 at 11:10 AM.

Based on record review and interviews with key personnel on February 9-11,2015, it was determined that the facility failed to ensure patients are free from chemical restraints and failed to follow their policy regarding the use of chemical restraints for 2 of 6 records reviewed (Record G and Record J).


The findings include:

1. Hospital Policy No. HC-PA-2041 (R3) Restraint Seclusion Policy states "Chemical restraint is not used with the CMHC [Central Maine Health Care] system".
2. A review of medical records G (a patient in the Intensive Care Unit) and J (an Emergency Department patient) contained documentation that chemical restraints had been used.
3. Record G's discharge summary, written by the physician, stated " In the night of January 16 and to January 17,the patient was [description of patients behavior], requiring four point restraints and chemical restraining".
4. Record J's physician discharge note states; "This patient was signed out to myself at 2 o'clock p.m. today. [He/she] received Ativan and Haldol along with the chemical restraints, [he/she] had physical restraints."
5. During an interview on February 11, 2015 at 10:25 AM regarding Record G, the Director of Care Management stated "the physician clearly documented the use of chemical restraints."

Based on document review and interview with key personnel on February 9-11, 2015, it was determined that the facility failed to ensure that the least restrictive restraint was utilized for 1 of six records reviewed (Record H).

The findings include:

1. A review of six medical records of patients who were restrained was conducted.
2. Record H failed to contain documentation of what type of restraint was utilized.
3. During an interview on February 11, 2015 at 10:25 AM, with the Director of Care Management, she stated, " I see no documentation of type of restraint used...."

Based on document review and interview with key personnel on February 11, 2015, it was determined that the facility failed to modify the Plan of Care to reflect the use of restraints for 1 of 6 records reviewed (record I).

The findings include:

1. A review of six medical records of patients who were restrained was conducted.
2. Record I failed to contain documentation that the plan of care was modified to reflect the use of restraints.
3. This finding was confirmed with the Director of Care Management on February 11, 2015 at approximately 1030.

Based on document review and interview with key personnel on February 10-11, 2015, it was determined that the facility failed to follow their restraint policy for 2 of 6 records reviewed (Record F, and Record G).

The findings include:

1. The Policy No. HC-PA-2041 (R3) Restraint Seclusion Policy states "assessments by a RN shall occur as often as indicated...and at least once per hour."
2. A review of six (6) medical records of patients who were restrained in the past four (4) months, was conducted.
3. Records F and G contained physician orders for patient monitoring every fifteen minutes, and the documentation to be done on a "Patient Monitoring Form".
4. Records F and G failed to contain documentation that the patients were monitored per the Physician orders and the restraint policy.
5. These findings were confirmed with the Intensive Care Unit Nurse Manager and the Director of Care Management during record reviews on February 10-11, 2015.
6. During an interview with the Intensive Care Unit Nurse Manager on February 11, 2015 at 1:21 PM, in reference to Record F, he stated, "I am confident that there is no nursing documentation or that 1:1 documentation by the CNA [Certified Nurses Aide] is in the chart".
7. During an interview with the Director of Care Management on February 11, 2015 at 11:32 AM, she stated,"It is my understanding that we don't use a "Restraint Monitoring Form" ...we should have removed it from the physician ordering set".

Based on document review and interview with key personnel on February 10-11, 2015, it was determined that the facility failed to ensure that physicians and other licensed independent practitioners who are responsible for the care of the patient were trained consistent with their restraint policy.

The findings include:

1. The Facility ' s Policy No. HC-PA-2041 (R3) Restraint Seclusion Policy states, "Hospital and Medical staff members shall receive training ...during the orientation process and annually. Such training shall take place before new staff members are asked to implement the provisions of this policy."
2. A review of the required CMMF [Central Maine Medical Family] 2014 Rapid Regulatory Clinical I and Clinical II provider training was conducted. The required restraint education is located in these educational modules.
3. A list of providers who work in areas where restraints may be ordered was requested for review, along with evidence that they had completed the required training.
4. There were three (3) providers who failed to demonstrate evidence of training or competency in regards to the Facility ' s Restraint Seclusion Policy.
5. This was confirmed with the Vice President of Surgical Services on February 11, 2015 at approximately 1500.

Based on document review and interview with key personnel on February 10-11, 2015, it was determined that the facility failed to ensure restraints were removed at the earliest possible time for 1 of 6 records reviewed.

The findings include:

1. The Policy No. HC-PA-2041 (R3) Restraint Seclusion Policy states "Discontinuation: a. Restraint shall be discontinued once the behaviors or situation that prompted the use of restraint are no longer evident..."
2. A review of six (6) medical records of patients who were restrained was conducted.
3. Record H failed to contain documentation that the restraint was removed at the earliest possible time.
4. During an interview with the Director of Care Management on February 11, 2015 at 10:25 AM, she stated, "I see no documentation ...that we took it off at the earliest time..."

Based on a tour of the physical plant and verified with the Director of Engineering on February 9-10, 2015, it was determined that the hospital failed to maintained the overall hospital environment in such a manner that the safety and well-being of patents are assured.
The findings include:
1. Nursing Station areas, including the dictation areas, throughout the hospital, were found to have soiled floors, chairs, and computer keyboards. In addition, the Emergency Department, trash receptacles were soiled and gouged on the outside of the container.
2. Throughout the hospital storage bins were found to be soiled.
3. Patient care equipment on wheels, computers on wheels and patient carts throughout the hospital were found dusty and soiled.
4. The hallway in the Radiology Department had chipped and gouged out door frames.
5. The Central Maine Heart Associates area had dusty flat surfaces, including some dusty patient equipment such as otoscopes. The conference room had dusty chair pedestals.
6. The Emergency Triage areas had dusty shelving, chairs and desk areas.
7. The T1 Unit, slip resistant flooring in the patient bathrooms were discolored and embedded with soil.
8. The Same Day Surgery patient exam room doors were soiled and scarred.
9. In the Dietary Department, the duct work above the coffee/catering area was soiled with areas of visible rust; several carts in the kitchen had rusty wheels which created a surface that was unable to be cleaned and sanitized, the outside face of the exhaust grill had visible cobwebs, the door to the Chef's office was soiled and gouged, the floor hallway outside the Chef's office had chipped tile, which was discolored and soiled. Floors, especially corners, throughout the Dietary area were soiled. Several wall areas throughout the kitchen had gouged out areas.
10. The dialysis treatment area located on M4 is composed of two separate rooms which prevents the staff from having constant observation of the patients during dialysis treatments. Per report of a unit physician, the dialysis rooms are used to provide treatment to many patients. The room contained a soiled radiator, torn and loose wallpaper, soiled blood pressure cart and patient scale. Additionally; the rooms had chipped baseboard, worn varnish on the cabinetry, the bathroom door was scarred with large areas of worn varnish all of which is not easily cleansed and sanitized.
11. NICU had worn and chipped counters at the nursing station and a large unsealed trim board on the wall which is no longer used of for hanging wall bins.
12. The Maternity pantry had worn rusted cabinets and an area on the wall that had a large unsealed board that is no longer being used to hang patient supplies.
13. The Operating Rooms had several metal tables and carts with rusty metal castors that were unable to be properly sanitized and multiple ventilation ducts were found to have accumulations of dust in them.
15. Multiple areas of the Emergency Department were found to have dirt, dust and trash. Trauma Bay had stretchers that were visibly with dust and hair. The Code Cart in the Trauma Bay had two (2) infant defibrillator pads with expiration date of 2015-01.
16. Emergency room 33 - Stretcher number one (1) mattress with a nonintact surface and unable to be properly sanitized.

Based on observation, document review, and interview with key personnel it was determined that the hospital failed to ensure that supplies and equipment were maintained to provide an acceptable level of safety and quality for patients consistent with facility policies.

The findings include:

1. The Clinical Policy "Crash Carts/Defibrillator/AED checks" states; "Inpatient Departments will check the integrity of the crash carts at a minimum of once per day".
2. A random review of crash cart logs was conducted. The M-1/Oncology Crash Cart/Defibrillator Quality Monitor log was reviewed. There was no documentation that the crash cart was checked on December 17-19, 2014, December 24, 2014, and December 29, 2014 and January 24, 2015, and February 4, 2015.
3. These findings were confirmed with the Nurse Manager on February 10, 2015 at 11:30 AM. She stated "It's my responsibility to assure that these checks are completed".
4. The Clinical Policy "Crash Carts/Defibrillator/AED checks states: "Outpatient... Departments that have a Crash Cart will check the integrity of the carts during normal operating hours".
5. The Emergency Department Room A Crash cart log was reviewed. The log failed to contain documentation that the cart was checked on October 2, 2014, October 9, 2014, October 17, 2014, October 21, 2014, October 23, 2014, and January 29, 2015.
6. The Emergency Department TR C Crash cart log was reviewed. The log failed to contain documentation that the cart was checked on October 9, 2014, October 21, 2014, November 28, 2014, November 30, 2014, December 6, 2014, and January 7, 2015.
7. The Emergency Department (ED) Pod C Crash cart log was reviewed. The log failed to contain documentation that the cart was checked on November 1, 2014, November 18, 2014, November 20, 2014, November 22, 2014, November 27, 2014, December 5, 2014, December 8, 2014, December 10, 2014, December 13, 2014, December 19, 2014, December 21-31, 2014, January 1-2, 2015, January 17-18, 2015, January 26, 2015, January 30, 2015, February 5, 2015, and February 7-9, 2015.
8. A crash cart located in the Emergency Department had an unlabeled log which was reviewed. The log failed to contain documentation that the cart was checked on November 15-18, 2014, November 21, 2014, and November 27, 2014.
9. These findings were confirmed with the interim ED Nurse Manager on February 10, 2015 at 11:10 AM, who stated "It's my responsibility to check the code cart logs... it's my responsibility to make sure the nurses check the carts..."