HospitalInspections.org

Based on observations and interviews with key staff on July 12 and 13, 2010, it was determined that the facility was not in complaince with the Federal Occupational Safety and Health Act of 1970 (OSHA) Regulations, Document Number: 120, titled 'Emergency Eye/Face Wash/Shower Requirements.'

Findings:

1. OSHA Document Number: 120 stated, "3. Installation: A. Eyewash equipment shall be located in an area that requires no more than 10 seconds to reach. B. The location of the eyewash unit shall be in a well-lit area and identified with a sign."

2. On July 12, 2010, an eyewash station was observed to be behind closed locked doors of patient bathrooms on the 2nd and 3rd floor North wings. Additionally, the location of the eye wash unit was not identified with a sign.

3. These finding were verified with facility staff on July 12, 2010. The sign was installed during the survey process and the doors were unlocked.

Based on review of the current Performance Improvement Plan and interviews with the Performance Improvement Director on July 12, 13, and 14, 2010, it was determined that the hospital failed to include all services and programs in their plan.

Findings include:

1. The Performance Improverment Plan was reviewed on July 13 and 14, 2010 and it stated, " Scope of Plan: The Performance Improvement Plan applies to all departments and programs at Acadia Hospital which include licensed inpatient psychiatric hospital beds, substance abuse services, partial hospital and intensive outpatient services, residential services, outpatient services, consultation/liaison services, and specialty clinical services.Specialty clinical services include Narcotics Treatment, Electroconvulsive Treatment, Neurology Services, Occupational Therapy Services, Psychology Services, and Care Coordination Services."

2. During an interview with the Director of Performance Improvement on July 14, 2010, he confirmed that that section of the document did not make it clear that all managerial, clinical and support processes were included in their scope.

Based on review of the current Performance Improvement Plan, other documentation provided and interviews with the Performance Improvement Director on July 13 and 14, 2010, it was determined that the hospital failed to measure, analyze, and track quality relate to all contractual agreements.

Findings include:

1. Five (5) randomly selected contracts were reviewed on July 14, 2010. Out of the five (5), the hospital could only provide evaluation of the quality in only one (1) of the contracts.

2. During interviews with the Performance Improvement Director and the Chief Operations Officer on July 13 and 14, 2010, it was stated that no consistent way of evaluating all contracts had been developed. The Chief Operations Officer did state that he knew that contracts related to the physical plant and environment were evaluated routinely.

Based on review of the hospital ' s policy book, review of the emergency equipment check sheet for May 2010 and interviews with key staff, it was determined that there was no documented evidence that the facility ensured that:
1. The emergency box was available on a daily basis
2. The oxygen was available on a daily basis.
3. The medications stored in the refrigerator were maintained consistently at the appropriate temperature.

Findings include:

The emergency equipment check sheets from 3N, 3S, and 2N were missing the following documentation:
a. E- Box - 3 of 62 daily check boxes were missing data.
b. Oxygen - 9 of 93 daily check boxes were missing data.
c. Refrigerator - 14 of 93 daily check boxes were missing data.

Based on observations and interviews on July 12 and 13, 2010, it was determined that the facility failed to maintain patient supplies and equipment to ensure and acceptable level of safety.

Finding include:

1. During the survey on July 12 and 13, 2010, the surveyor observed that the air handlers in the kitchen and in the steam table area were covered with dirt and debris.

2. During the survey on July 12, and 13, 2010, the surveyor observed the call bells in patient bathrooms were not working on the second and third floor North and South wings. This was discussed with a nurse unit supervisor who stated the system would not ever be turned off.

3. One sharp container in the ECT room was located on the table, not secured to the wall. Two small containers were found not secured in the nurses station in the Observation Unit's nurses station.

4. These findings were verified by the Plant Operations Manager during the survey on July 12 and 13, 2010.

5. All findings were corrected during the survey on July 12 and 13, 2010.

Based on observations, staff interviews, and record reviews the facility failed to ensure that the infection control officer was responsible for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel.

Findings include:

1. The Acadia Hospital Policy titled, '# IC-110: Bloodborne Pathogens Exposure Control Plan and Management of Human Bite-Related Injuries and Ryan White Act Compliance: Sections III. A. Standard Precautions 1., III. D. Personal Protective Equipment 6. a. and III. F. Laundry 5. a-c.' was reviewed on July 13, 2010.

2. An observation during a facility tour between 0845 and 1000 on 07/13/10, a Unit 2 North a staff person was observed carrying linens i.e.: unfolded rolled blankets and sheets. Linens were in full contact with upper arms and held against the staff persons clothing. Linens were carried through the hall, in close proximity to patients and the survey team to a dirty utility area where the linens were deposited. The staff person exited the dirty utility area and then proceeded to the 2 North nursing station where he/she handled multiple items and then exited to a patient care area. Hand hygiene was not performed by the staff person at any time during this observation.

3. This observation and the staff person involved were immediately reported by the surveyor to the Interim Director of Nursing (DON), who was in attendance with the survey team.

4. During an interview with the Interim Director of Nursing on 07/13/10, the DON revealed that the facility procedure for handling contaminated linen is to place the linen in a linen cart and then to transport the contaminated linen to the dirty utility area.

5. Review of the policy and procedure manual on 07/13/10 and 07/14/10 did not provide evidence that the facility had a specific policy for the handling of contaminated linens. A review of all related policy and procedure manuals revealed that Acadia Hospital Policy # IC-110 provided procedures for Standard Precautions, Hand Hygiene and handling of contaminated laundry.

Based on a review of documents and interviews with key personnel on July 14, 2010, it was determined that the hospital failed to ensure specific organ, tissue, and eye procurement requirements were met.

Findings include:

1. Review of the existing Organ, Tissue, and Eye Procurement (OTE) documents on July 14, 2010, revealed that the hospital did not have an agreement with the New England Organ Bank (organ procurement organization).

2. Review of the hospital OTE program procedure on July 14, 2010, revealed that it was incomplete and did not incorporate coordination, review, and approval with the organ procurement organization.

3. During an interview on July 14, 2010, the Director of Quality confirmed that the hospital did not have an agreement with the New England Organ Bank and the existing hospital procedure required revision and coordination with the organ procurement organization to properly establish the OTE program.

4. The hospital provided the survey team with a signed Memorandum of Understanding between Acadia Hospital and New England Organ Bank on July 14, 2010, the last day of the survey.


The cumulative effects of these finding resulted in this Condition of Participation being out of compliance.

Based on an interview with the Chief Medical Officer, the Chief of ECT (Electroconvulsive Therapy), review of credentialing files, and review of medical records all on July 14, 2010, it was determined that the Hospital was not in compliance with the Condition of Participation Anesthesia Services as the Hospital could not assure that anesthesia was provided in a safe, well-organized manner, under the direction of a qualified physician.

Findings include:

1. Anesthesia, including the use of paralytic agents, is administered to patients at Acadia Hospital who undergo Electroconvulsive Therapy, (ECT).

2. Anesthesia and respiratory support for patients is provided by Certified Registered Nurse Anesthetists, (CRNA ' s).

3. The Chief Medical Officer identified the Chief of the ECT service as the physician in charge of anesthesia.

4. During an interview, the director of the ECT service said that she did not believe that she was responsible for Anesthesia Services. She said she does not perform performance improvement activities related to the administration of anesthesia or respiratory support.

5. The Chief of the ECT service stated that the selection and use of anesthetic and paralytic agents is not part of standard training for psychiatrists. She also said that not all physicians at Acadia provide ECT as they lack this training.

6. The credentialing file of the director of the ECT service did not specify privileges to order anesthetic agents, nor was there evidence that she had been appointed as the Chief of Anesthesia.

7. In Maine, a licensed physician must order anesthetic agents administered by a CRNA.

8. Five (5) ECT records were reviewed. None (0), of the records contained physician authentication for the anesthetic agents administered by CRNA ' s.

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.