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Based on observation, interviews and record reviews, the hospital failed to ensure there were sufficient safeguards in place to provide confidentiality of patient records and information, and that all staff honored and promoted patient rights. The cumulative effect of the deficient practice resulted in noncompliance with this Condition of Participation.

Findings:

1. The hospital failed to ensure that there were sufficient safeguards and facility design controls to ensure protection of patient records from unauthorized access and use. This failure resulted in the hospital's electronic medical record computers and screens being accessible to unauthorized use and access. (see A-0117, A-0143, and A-0147 for details).

The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.

Based on review of records and interview, the hospital failed to ensure that a patient or their representative was informed of the patient's rights in advance of furnishing care for 2 of 54 sampled inpatient records (Patient #15 and #25).

Findings:

1. A record review of the electronic documentation for Patient #15 failed to identify evidence that this patient received or was offered Patient Rights information prior to receiving patient care.

An interview on 2/21/19 at 1:00 P.M. with the Clinical Information Specialist confirmed there was no evidence of documentation that Patient #15 received or was informed of the Patient Rights.

2. On 2/21/19 between 1:15 PM and 3:00 PM, a review of Patient #25's inpatient record was completed with an assigned hospital representative.

The "Event Management" document in the clinical record indicated that the patient was admitted to the Emergency Department on 10/11/18 at 12:17 PM and was admitted to the hospital.

The "Document List" indicated in the row of "Patient Rights - Admissions/ED MMC/MMP" the date of 10/12/18.

No evidence was found by the hospital representative in the patient's record to indicate the patient was informed of his/her rights before care was furnished to the patient on 10/11/18.

Based on observations and interviews, the hospital failed to ensure the personal privacy of patients was safeguarded consistent with current standards of practice for 1 of 65 sampled patients (Patient #65).

Finding:

While conducting a tour of the 4th floor of the Richards wing, on February 27, 2019 at 1:00 PM, the surveyor observed a yellow laminated sign posted on the door to enter Room 418 which stated, "BEHAVIOR PRECAUTIONS CHECK-IN WITH NURSE."

In an interview with the Registered Nurse (RN) Manager on February 27, 2019 at 1:05 PM, the surveyor was informed that the sign was not a standard within the hospital but was one that the staff on the floor developed for this specific patient. The RN Manager stated that the patient has a Behavioral/Mental Health condition and has aggressive outbursts and behaviors that have threatened staff safety; the staff felt that the use of this sign was appropriate to alert staff to check this patient's care plan for specific behavioral interventions before entering the patient's room. The RN Manager stated the intent of the sign was to highlight the need for staff precautions for safety and not to identify that this was a psychiatric patient.

This finding was reviewed with the Associate Chief Medical Officer and the Director of Accreditation and Regulatory Compliance on February 27, 2019.

Based on observations and interviews, the hospital failed to ensure patient's clinical records were kept confidential on many of the hospital's inpatient units including, but not limited to R-4, the Adult Cardiac Catherization Unit, R-7, Special Care Unit 2, Special Care Unit 3, Special Care Unit 4, and the Emergency Department.

Findings:

1. On 2/19/19 at 2:35 PM, during tour of R-4, 2 surveyors and the Director of Professional Practice observed a Provider's clipboard resting on a corridor handrail left unattended outside patient room 404. The clipboard contained a list of patient room numbers, patient names and patient information. The patient information was left unattended in the corridor where unauthorized personnel may pass through. At the time of the observation, the surveyors confirmed the finding with the Director of Professional Practice.

2. On 2/20/19 at 8:50 AM, during tour of the ACCU [Adult Cardiac Catherization Unit], a surveyor observed a nurse logging onto a computer workstation next to a two-patient curtained area located near the surgical cath-lab suite with a walk area near the desk. When the nurse walked away, the computer terminal remained visible with patient information and remained visible until the nurse returned. Any person standing in the walkway of this nurse station would be able to see this terminal screen. This finding was confirmed by a second surveyor on 2/21/19, at 12:00 PM, who observed the same screens open with patient information displayed on one.

3. On 2/20/19 at 10:10 AM, during tour of R-7, two surveyors and the Director of Professional Practice observed a nurse logged on a computer charting workstation outside a patient room located in the corridor where unauthorized personnel may pass through. The surveyors could read the patient identifying information on the top left hand corner of the terminal and in larger font mid screen from across the corridor. The surveyors tracked the length of time patient information stays up on the screen, should a nurse fail to sign-out; the length of time was over 4 minutes. At the time of the observation, the surveyors confirmed the finding with the Director of Professional Practice.

4. On 2/21/19 between 9:20 AM and 9:48 AM, two surveyors were in the Special Care Unit (SCU) 4 adjacent to the desks in the hallway by Room 1049 where the following was observed in relation to a computer screen:

- At 9:20 AM, the computer screen, at the desk area beside Room 1049, displayed medical information regarding the patient in Room 1049. No staff members were in this area at the time.

- At 9:22 AM, the computer screen display changed and indicated the following: "[First name of an individual and an initial], Not you? Tap your badge to log in". The surveyor touched the mouse and the screen again changed to the display the medical information regarding the patient in Room 1049.

- At 9:27 AM, an RN went to the desk area in the hallway by Room 1049 to use the phone. At that time, the computer screen continued to display the medical information regarding the patient in Room 1049. This RN did not touch this computer to log off to prevent the visible patient information from being displayed.

- At 9:33 AM, the computer screen display again changed. The computer screen displayed the same medical information as it did at 9:22 AM.

- At 9:38 AM, the surveyor touched the mouse and the computer screen again changed to the display the medical information regarding the patient in Room 1049.

- Between 9:38 AM and 9:41 AM, two Registered Nurses (RNs) and a laboratory staff member walked by the computer screen which continued to display the information regarding the patient in Room 1049. None of these staff members touched this computer to log off the visible information.

- At 9:41 AM, a RN walked by the desk area that had computer screen displaying the medical information regarding the patient in Room 1049. This RN did not touch this computer to log off the visible information. In addition, at this same time, a physician came from Room 1048 and sat at the desk area and started to use the computer which was located beside the computer screen that displayed the information regarding the patient in Room 1049. This Physician did not touch this computer to log off the visible information.

- At 9:43 AM, the computer screen display again changed. The computer screen now displayed a message that there was the ability to click the word "okay". The Physician remained at the computer beside this computer screen.

- At 9:45 AM, one of the surveyors asked the Nurse Manager to come to the computer. At that time, the computer screen continued to display the word "okay". When "okay" was clicked, the screen again displayed the information regarding the patient in Room 1049. The Nurse Manager logged off the computer; thus, no patient information was displayed. The Nurse Manager was made aware that this patient information was accessible for 25 minutes.

5. On 2/21/19 at 9:22 AM, two surveyors observed a piece of paper with hand written notes related to patients on the desk, which was located in the hallway between Room 1048 and 1049 in SCU 4. No staff were in this area at the time.

Between 9:22 AM and 9:48 AM, the surveyors remained in the area of the desk and the paper remained on the desk.

At 9:48 AM, the Nurse Manager was observed moving the piece of paper from the desk. The Nurse Manager was made aware that this piece of paper had been observed by surveyors to be on the desk for at least 25 minutes.

6. On 2/21/19 at 9:26 AM, two surveyors observed a clipboard on the desk area in the hallway across from the desk in the hallway between Room 1048 and 1049 in SCU 4. This clipboard, which was labeled "SCU Charge Nurse", contained papers that had the following information; the patient's names, room number, hospital service, attending provider, admission diagnosis, code status, and principal diagnosis.

Between 9:26 AM and 9:48 AM, the surveyors remained in the area and the clipboard with patient information remained on the desk.

At 9:48 AM, the surveyor made the Nurse Manager aware of this observation.

7. On 2/21/19 at 9:51 AM, two surveyors observed a RN at the computer that was outside of Room 1036 in SCU 3. The RN walked away from the computer and the computer screen displayed patient information that could be visible by anyone in the area. The RN went into the main nursing station and then turned around, went back to the computer, logged off, and then went back to the main nursing station.

8. On 2/21/19 at 10:04 AM, two surveyors observed a RN at the computer outside of a Room 1035 in SCU 3. The RN then went into the patient's room. One of the surveyors walked by the computer screen and observed that the medication administration record for the patient in Room 1035 was displayed on the screen. Another RN went over to the computer as the surveyor was walking by and stood there until the RN in the patient's room came out, approximately one minute later.

9. On 2/21/19 at 10:09 AM, two surveyors observed a RN come out of Room 1036 in SCU 3 and go to the computer located outside of the room. The nurse logged into the computer and then left the area without logging off the computer. One of the surveyors walked by the computer and observed the medication administration record for the patient in Room 1036. At 10:12 AM, another RN went to this computer and logged the RN out of the computer.

10. On 2/21/19 at 10:14 AM, two surveyors observed a RN at the computer outside of Room 1033 in SCU 3 and then she went into the patient's room without logging off the computer. One of the surveyors observed the computer screen which contained medical information related to the patient in Room 1033. The RN returned to the computer approximately one minute later.

11. On 2/21/19 at 10:37 AM, two surveyors observed a RN sitting in the hallway outside Room 1022 in SCU 2 charting in the computer. When surveyors were behind the RN and approximately five minutes elapsed, they were able to see the patient's name and what the RN was charting about the patient.

12. On 2/21/19 at 10:57 AM, two surveyors observed a RN at the computer outside Room 1026 in SCU 2 and then she went into the patient's room without logging off the computer. The computer screen had the patient's medication record visible. The surveyors observed the RN administer medications to the patient in the room. She left the patient's room at 11:06 AM at which time she logged off the computer.

13. On 2/19/19 at 2:36 PM while conducting a tour of the Emergency Department, the surveyor observed the triage nurse in the work station closest to the patient registration desk walk away from the triage station with the computer screen elevated and turned so that it was visible to people outside of the triage area and those walking to and from the patient registration desk. The triage nurse did log off the computer and while the triage nurse was off the unit, the surveyor observed 2 hospital staff access the computer to review patient records under the computer log in information for the triage nurse who was not in sight. This finding was confirmed with the triage nurse on 2/19/19 at 2:41 PM who stated that she thought she had left the computer screen in a position so that it wasn't visible, and acknowledged that she had not signed off the screen leaving the computer accessible and the screen visible while she had gone off the unit to obtain medications.

14. On 2/19/19 at 2:58 PM while conducting a tour of the Emergency Department, the surveyor noted that there were several computer screens that were in use with patient identifiable information on them as nurses were charting and discussing patients and patient care among themselves at the nurses' station. The surveyor observed that there were no walls, glass partitions or any sound barrier devices in use, and that several of the computer screens were visible to patients, and visitors who were in ED beds in the hallways within 6 feet of the nurses stations and computers. The surveyor observed several nurses leave the computers with screens still active and opened as they went into various patient rooms to assist patients. This finding was confirmed with the ED Nurse Manager on 2/19/19 at 3:10 PM who acknowledged that not all computers had screen shield devices in use, and some of those that did were still visible to people standing in the hallway adjacent to the nurse station desk area; she advised that the computer screens are supposed to automatically shut off after 1 minute of non-use.

Based on record reviews, observations, and interviews, the hospital failed to ensure that scheduled medications were administered as ordered for 4 of 54 Patients (#21, #22, #55, #63).

Findings:

1. A record review of the February 2019 MAR for Patient #21 identified a 2/12/19 medication order, "Clotrimazole Oral Troche 10 mg. po three times daily." This medication was not administered as ordered on 2/18/19 at 15:46 P.M. and did not document any reason why. In addition, this medication was not administered as ordered on 2/19/19 at 15:56 P.M. and staff documented 'Other' with no reason identified.

2. A record review of the February 2019 MAR for Patient #22 identified a 1/5/19 medication order, "Chlorhexidine 0.12% mouth Solution 15 ml. every 12 hours swish and spit." This medication was not administered as ordered on 2/11/19 at 10:05 A.M., and staff documented 'contraindicated', without a reason why. This medication was not listed on the allergy list. This medication was not administered as ordered on 2/13/19 at 8:59 A.M., 2/13/19 at 20:43 P.M., 2/14/19 at 9:23 A.M., 2/14/19 at 21:27 A.M., and 2/21/19 at 10:30 A.M. Staff documented 'Order Parameters Not Met,' there was no explanation what parameter was not met. In addition, this medication was not administered as ordered on 2/20/19 at 10:00 A.M. and staff did not document any reason why.

An interview on 2/22/19 at 12:30 P.M. the Clinical Informatic Specialist indicated that the records for Patient (#21, and #22) did not include all the required medication documentation for scheduled medications ordered to be administered.

The medication policy indicates "Medications are administered at the scheduled time. Variations of 30 minutes before to 30 minutes after scheduled times are acceptable" and "The administration of medications must be documented in the patient's medical record, including date, 24 h-time, initials or electronic signature of healthcare professional administering the medication, along with any monitoring information required as part of the administration process."

3. On 2/21/19 at 9:15 AM, during medication administration on Pavilion-6 (P-6), 2 surveyors observed a Registered Nurse remove a Lidocaine patch from patient #63's shoulder and place a new Lidocaine patch to the patient's shoulder. In review of the patient's order for the Lidocaine patch it states: Lidocaine 5% patch - Apply under the right breast along the most painful rib. On 2/21/19 at 10:35 AM, in an interview with the Director of P-6, he/she was made aware the Registered Nurse did not administer medication according to Provider orders and the surveyor confirmed the finding.

4. On 2/21/2019 at 11:00 AM, surveyor observed a Registered Nurse (RN) #63 comparing the Doctors order, for Patient #55, for the medication Roflumilast (Daliresp) to the pill pack label. RN #63 and surveyor observed that the order was for 500 mcg and the pill pack was labeled 500 mg. The RN #63 did not give the medication, she called and informed the pharmacy.

On 2/22/2019 at 10:30 AM, surveyor reviewed the Medication Administration Record for Patient #55, noted that the medication labeled Daliresp 500 mg was given on 2/18/19 at 1:01 PM by RN #85, 2/19/19 at 09:43 AM by RN #86, on 2/20/19 at 09:51 AM by RN #87, and on 2/21/19 at 1:59 PM by RN #88 despite the Doctors order for Daliresp 500 mcg. The 3 Registered Nurses did not recognize that the label and the Doctors order did not match.

On 2/25/19 at 10:30 AM, surveyor interviewed the Medication Safety Officer who stated for non-formulary medications they use a manual process. The Medication Safety Officer explained the non-formulary medication process is as follows: the medication is borrowed from the out-patient pharmacy, doctors order is manually entered in to their labeling software by a pharmacy technician, repackaged in MILT (Medi-Dose Information Labeling Technology)/automated label machine, and then there is a process for two Pharmacists to "double and triple check" the information entered and printed was correct. He stated that the pharmacy technician entered the wrong dose-she entered 500 mg vs 500 mcg. The Medication Safety Officer stated, "it's obvious there was a break down with the checks after that, and that is a problem". He said after investigating, the medication only comes in mcg, so the medication was correct, just labeled incorrectly. The Medication Safety Officer stated that the log showed that 10 pill packs were made labeled "Daliresp 500 mg".

On 2/27/19 at 09:30 AM, surveyor interviewed the Senior Director of Pharmacy who stated that he had interviewed the Pharmacy Technician and the two Pharmacists involved with the mislabeled medication pack Daliresp 500 mg. They both stated that when they looked at the order they saw milligrams not micrograms. The Senior Director of Pharmacy stated it was definitely human error and they are working on how to avoid it happening again. He explained that it was non-formulary drug and they got it from an outside Pharmacy. He also added that typically they don't have orders for medications in micrograms. Additionally, he stated that the medication came in bulk and it was a manual process to package it. The Senior Director stated, "It was the right drug, the right route, right dose, right time but was mislabeled."

On 2/27/19 at 10:45 AM, surveyor interviewed a Pharmacist that was part of one of the "checks" regarding the Daliresp 500 mg pill pack. This Pharmacist stated that she guessed that she was in a rush, she was behind and the nurse [on the floor, caring for patient] was pushing for her to get the medication ready. She stated that when she looked at the order she saw milligrams not micrograms. She added that micrograms are not typically ordered. She added that she would definitely be more cautious in the future.




30015




40836

Based on record review and interview, the hospital failed to ensure that medical records were accurately written for 4 of 57 inpatient records reviewed (Patient #25, #66, #67, and #68).

Findings:

1. On 2/21/19 between 1:00 PM and 3:00 PM, Patient #25's record was reviewed with an assigned hospital representative.

Patient #25 has had a physician's order for Heparin to be administered, via injection, every 12 hours, since 10/11/18. Between 1/1/19 and 2/20/19, the patient's medication administration record indicated the patient received Heparin five times (once on 1/8/19; once on 1/12/19; once on 1/16/19; once on 2/3/19; and once on 2/20/19) and the Heparin was not given 97 times. Documentation indicated the patient refused the medication for 92 of the 97 times the Heparin was not given.

Documentation, dated 1/7/19, 1/14/19, 1/28/19, 2/4/19, and daily from 2/11/19 through 2/20/19, by the Physician, Physician Assistant and cosigned by the Physician, or Nurse Practitioner and cosigned by the Physician was reviewed. Every note, under the section "Global Issues" indicated the following: "DVT prophylaxis: .... SQ Heparin. Is on chemoprophylaxis or has been < [less than] 7 days without chemoprophylaxis, no DVT screening needed".

There was no evidence that the Physician, Physician Assistant, and/or the Nurse Practitioner were made aware the patient was not receiving the Heparin and their notes continued to state "SQ Heparin" under DVT prophylaxis; therefore, the notes were not accurate.

The hospital representative confirmed, at the time of the review, that the notes, dated 1/7/19, 1/14/19, 1/28/19, 2/4/19, and daily from 2/11/19 through 2/20/19, indicated "SQ Heparin".

2. On 2/25/19 a medical record review was conducted for Patient #66 which denoted the patient was admitted to the CTICU Unit from the operating room at 12:16 PM on 2/13/19. The Anesthesia Transfer of Care report denoted that Patient #66 was unresponsive, intubated and on a ventilator at the time of admission to the CTICU with vital signs on admission to the CTICU of blood pressure of 74/60, a pulse of 100 and respirations of 15 ventilated. The nurses admission assessment conducted at 1:00 PM documented Patient #66 was unresponsive, on a ventilator with continuous sedation infusing, and that the patient had a psychosocial and musculoskeletal assessments that were "Baseline for patient." Additionally, there was a medical record entry at 2:00 PM that stated the patient's teeth, tongue and gums were brushed and that the patient did this independently (without staff assistance). On 2/25/19 at 3:48 PM this finding was reviewed with the Registered Nurse in Clinical Informatics who confirmed the finding and was unable to explain how an unconscious, sedated patient who was on a ventilator could have participated in a psychosocial and musculoskeletal assessment, or brush his/her own teeth and gums.

3. On 2/25/19 a medical record review of patient #67 which denoted the patient was admitted to the SCU#4 unit from the emergency department on 12/29/18 at 7:59 PM was conducted. The medical record contained documentation by the RN at 4:24 PM, 6:34 PM, 8:00 PM, and 11:00 PM which all stated that Patient #67 had soft wrist restraints in use because the patient was attempting to remove medical devices and did not respond to least restrictive measures and verbal limit setting; at the same time of these entries in the medical record supporting the continued use of soft restraints, the nurse documented that the patient was asleep. Additionally, the medical record documented that blood pressures were being done at 30 minute intervals with no indication of what interventions were implemented after the 10:00 PM blood pressure of 76/64 (a significant decrease from the 9:30 PM blood pressure of 155/90). The medical record denoted a blood pressure of 53/42 at 10:00 PM, 83/63 at 11:30 PM and then a change to 15 minute checks at 11:45 PM with a blood pressure of 83/70. On 2/25/19 at 11:23 AM the surveyor reviewed this finding with the Registered Nurse in Clinical Informatics who confirmed the finding and was unable to explain what had occurred or why there was a delay in the response to the significant change in the blood pressure; she stated, "it's hard to get a clear picture of what happened from one data point to the next, I don't see any notes."

4. On 2/25/19 a medical record review was conducted for Patient #68 which denoted the patient was admitted to the CTICU Unit from the operating room at 1:28 PM on 1/29/19. The Anesthesia Transfer of Care report denoted that Patient #68 was unresponsive, intubated and on a ventilator at the time of admission to the CTICU. The nurses change of shift assessment conducted at 7:00 PM documented Patient #68 was on a ventilator with continuous sedation infusing, and that the patient was "Alert and oriented x 4. On 2/25/19 this finding was reviewed with the Registered Nurse in Clinical Informatics who confirmed the finding and was unable to explain how a new nurse to this patient was able to determine that a sedated patient who was on a ventilator could be alert and orient x 4.

Based on record review and interview, the hospital failed to ensure all orders were dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient for 2 of 54 Patients (#20 and #22).

Findings:

A record review for Patient #20 indicated there was a 2/18/19 at 6:16 A.M. infusion order, "NaCl 0.9% 50 ml/Hr. Intravenous Infusion" that was not dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient.

A record review for Patient #22 indicated there was a 12/24/18 at 15:56 P.M. pharmacy order, "Sodium Bicarbonate 150 meq. 'Straight Drug' once." and a 12/19/18 at 16:05 P.M. radiology order, "X-Ray of Abdomen 1VW 1 time imaging" that were not dated, timed, and authenticated promptly by the ordering practitioner or by another practitioner who is responsible for the care of the patient.

An interview on 2/22/219 at 12:30 P.M. with the Clinical Informatic Specialist and on 2/27/19 at 1:30 P.M. with the Consultant of Medical Affairs indicated there was no evidence that the orders for Patient #20 and #22 were dated, timed, and authenticated by the practitioner within 48 hours.

The Prescribing of Medication Policy indicates "Verbal Orders or telephone orders must be documented in the patient's medical record and co-signed according to MMC Institutional Policy-Verbal Communication of Medical Orders...Authentication-The responsible practitioner must authenticate telephone or verbal orders within forty-eight (48) hours."

Based on observations and interviews, it was determined that the facility failed to ensure safe standards of practice were followed regarding labeling of medications in the pharmacy.

Finding:

On 2/21/2019 at 11:00 AM, surveyor observed Registered Nurse (RN) #63 comparing the Doctors order, for Patient #55, for the medication Roflumilast (Daliresp) to the pill pack label. RN #63 and surveyor observed that the order was for 500 mcg and the pill pack was labeled 500 mg. The RN #63 did not give the medication, she called and informed the pharmacy.

On 2/22/2019 at 10:30 AM, the surveyor reviewed the Medication Administration Record for Patient #55 and noted that the medication labeled Daliresp 500 mg was given on 2/18/19 at 1:01 PM by RN #85, 2/19/19 at 09:43 AM by RN #86, on 2/20/19 at 09:51 AM by RN #87, and on 2/21/19 at 1:59 PM by RN #88 despite the Doctor's order for Daliresp 500 mcg. The three RNs did not recognize that the label and the Doctor's order did not match.

On 2/25/19 at 10:30 AM, the surveyor interviewed the Medication Safety Officer who stated for non-formulary medications they use a manual process. The Medication Safety Officer explained the non-formulary medication process is as follows: the medication is borrowed from the out-patient pharmacy, doctors order is manually entered in to their labeling software by a pharmacy technician, repackaged in MILT (Media-Dose Information Labeling Technology)/automated label machine, and then there is a process for two Pharmacists to "double and triple check" the information entered and printed was correct. He stated that the pharmacy technician entered the wrong dose-she entered 500 mg vs 500 mcg. The Medication Safety Officer stated, "it's obvious there was a break down with the checks after that, and that is a problem". He said after investigating, the medication only comes in mcg, so the medication was correct, just labeled incorrectly. The /Medication Safety Officer stated that the log showed that 10 pill packs were made labeled "Daliresp 500 mg".

On 2/27/19 at 09:30 AM, surveyor interviewed the Senior Director of Pharmacy who stated that he had interviewed the Pharmacy Technician and the two Pharmacists involved with the mislabeled medication pack Daliresp 500 mg. They both stated that when they looked at the order they saw milligrams not micrograms. The Senior Director of Pharmacy stated it was definitely human error and they are working on how to avoid it happening again. He explained that it was non-formulary drug and they got it from an outside Pharmacy. He also added that typically they don't have orders for medications in micrograms. Additionally, he stated that the medication came in bulk and it was a manual process to package it. The Senior Director stated, "it was the right drug, the right route, right dose, right time but was mislabeled".

On 2/27/19 at 10:45 AM, the surveyor interviewed a Pharmacist that was part of one of the "checks" regarding the Daliresp 500 mg pill pack. This Pharmacist stated that she guessed that she was in a rush, she was behind and the nurse [on the floor, caring for patient] was pushing for her to get the medication ready. She stated that when she looked at the order she saw milligrams not micrograms. She added that micrograms are not typically ordered. She added that she would definitely be more cautious in the future.

Based on observations and interviews, the hospital failed to ensure that medications were secured and locked when not in use in R-4 and the surgical services department.

Findings:

1. On 2/19/19 2:45 PM, during tour of R-4, 2 surveyors observed 2 Registered Nurses that were signed into the Pyxis medication dispensing machine on 2 different occasions, and when finished in Pyxis both nurses failed to sign out. Both Registered Nurses and Certified Nurse Assistants have access to the medication rooms. The Pyxis machines automatically time out after 60 seconds, leaving a one minute window for unauthorized personnel to access medications, including scheduled medications, under another staff member's log on. On 2/19/19 at 2:50 PM, in an interview with the Director of Professional Practice, the surveyors informed him/her of the medication security concern and confirmed the finding.

2. An observation on 2/26/19 at 10:30 A.M. of the surgical services department Certified Nurse of the Operating Room (CNOR) office identified five blue colored ampules of Provay Blue Intravenous 50 mg./10 mls. or 5 mg./ml. lying on her desktop.

An interview on 2/26/19 at 10:30 A.M. with the surgical services CNOR indicated that an ampule Provay Blue broke in the Solution Room, the staff person removed the package of ampules affected, placed them on her office desk unsecured instead of returning them to the pharmacy.

The 6/12/17 policy of the surgical services department indicates "These procedures ensure the safe, secure, and controlled conditions required for the storage of medications...: k. Medications are secure."






30015

Based on interviews and review of medical records, it was determined that the facility failed to immediately report to the attending physician a drug administration error in 1 of 5 medical records. (Record #:64)

Finding:

On February 27, 2019, at approximately 1:45 PM, patient #64's medical record was reviewed with the Consultant of Medical Affairs and the Manager of Clinical Informatics. Patient #64 had an order for Hydromorphone tablet 6 milligrams orally every 3 hours PRN [PRN or pro re nata means as needed] for pain.

The Hydromorphone was administered on 11/22/18 as documented in the MAR [medication administration record] at 9:44 AM and 10:48 AM. There was no documentation that this medication error had been reported immediately to the physician. This finding was confirmed by the 2 staff who reviewed the medical record with this surveyor.

Based on observations, document reviews, and interviews, the Condition of Participation (CoP) for Physical Environment was not met as evidenced by the hospital's failure to ensure that the Brighton Campus, located at 335 Brighton Avenue in Portland, was in compliance with NFPA 101 Life Safety Code, 2012 Edition Section 19.1.6.1. as evidenced by the failure to ensure fire barrier separations were present between the additions on the ground, first, second, and third floor.

Findings:

1. Standard: §482.41(b) Life Safety from Fire also known as A-0709 - Based on observations, document reviews, and interviews conducted by life safety code surveyors, the hospital failed to ensure that life safety code requirements were met in 3 of 4 building locations (22 Bramhall Street, Portland; 335 Brighton Avenue, Portland, and 84 Campus Drive, Scarborough). Please see the CMS Form 2567 for Event ID 9LPM21 and for details.

2. Standard: §482.41(c)(2) also known as A-0724 - Based on observations, review of records and interviews, the hospital failed to ensure that Code Carts were checked daily to ensure supplies were available in case of any emergency for 2 of 5 crash carts in the Surgical Services Department and ensure the safety of non-medical electrical equipment used in 3 of 4 patient areas (Operating rooms, Special Care Unit-2, and Radiology). Please see A-0724 for details.


The cumulative effect of these deficient practices resulted in noncompliance with this Condition of Participation.

Based on observations, document reviews, and interviews conducted by life safety code surveyors, the hospital failed to ensure that life safety code requirements were met in 3 of 4 building locations (22 Bramhall Street, Portland; 335 Brighton Avenue, Portland, and 84 Campus Drive, Scarborough).

Findings:

During the life safety code survey, the following life safety code requirements were not met:

1. K161, K211, K223, K224, K321, K351, K355, K363, K761, and K908 at the Bramhall Street location. Please see the CMS Form 2567 for Event ID 9LPM21 for details.

2. K100, K161, K211, and K372 at the 335 Brighton Avenue location. Please see the CMS Form 2567 for Event ID 9LPM21 for details.

3. K161 and K351 at the 84 Campus Drive Scarborough location. Please see the CMS Form 2567 for Event ID 9LPM21 for details.

Based on observations, review of records and interviews, the hospital failed to ensure that Code Carts were checked daily to ensure supplies were available in case of any emergency for 2 of 5 crash carts in the Surgical Services Department and ensure the safety of non-medical electrical equipment used in 3 of 4 patient areas (Operating rooms, Special Care Unit-2, and Radiology).

Findings:

1. The 1/30/15 Code Blue: Cardiopulmonary Resuscitation (CPR) Team policy indicates "A registered nurse or staff member, in the patient care area on which the defibrillator/monitor is stored, will be responsible for checking and ascertaining that it is equipped and in operating condition on a daily basis and after each use" and "A staff member will inspect the expiration date and the seal's integrity of the Emergency Cart, including the sealed boxed [sic] on the top of the cart daily when the department/unit is open. If the cart's seal is broken, notify (CSD) Central Sterile Department) to replace the cart immediately."

Observations of the Main Operating Room Code Cart on 2/25/19 at 10:30 A.M. identified that the Code Cart was not checked daily in the month of January and February 2019 for the adult and Pedi Code Carts.

Observations of the Operating Room #30 Code Cart on 2/26/19 at 8:30 A.M. identified that the Code Cart was not checked daily in the month of January and February 2019 and that there was an opened package of electrode pads that were not replaced after opening.

An interview on 2/26/19 at 8:30 A.M. with the Certified Nurse Operating Room (CNOR) confirmed that staff have failed to document that they have checked the Code Carts daily and signed off that this procedure was completed.


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2. Policy Title: Employee and Department Owned Electrical Appliance Type Devices states: "Policy: Prior to use or whenever discovered, line/a.c. powered devices (those devices with an electrical cord) shall be inspected by the Nursing Director, Nurse Manager or Department Director, or designee of the representative area in which that appliance will occur as follows:"

On 2/20/2019 at 10:05 AM the Manager of Facilities confirmed that they do not do safety checks on non-medical electrical appliances.

On 2/21/2019 at 6:20 AM the Director of the Operating Rooms stated that she was not aware that it was their responsibility to check the electrical safety of non-medical appliances (such as their radios). She thought clinical engineering took care of that.

On 2/25/2019 at 9:55 AM, The Clinical Engineering Director stated that they do not inspect non-medical equipment.

On 2/25/2019 at 10:35 PM, a Nurse Manager for Special Care Unit -2 stated that they do not inspect the fans, as they get a new one for each patient.

On 2/25/2019 at 12:55 PM, The Director of Radiology stated, in regard to non-medical electrical appliances is that they do not check them, as the assumption is they are safe.

Based on observations, interviews, and document reviews, it was determined that the Condition of Participation for Infection Control was not met as evidenced by the hospital's failure to have a system in place to ensure staff had appropriate and fully functioning infection control gowns, that staff utilized the infection control gowns appropriately and that a system to maintain a sanitary environment to prevent potential infections in 21 of 29 in-patient care areas (Dietary Services, Emergency Department, Operating Rooms, Bean-6/Barbara Bush, Bean-5 Gibson Pavilion, Special Care Units, Radiology, Richards-9, Richards-8, Richards-7, Richards-6, Richards-5, Richards-4, Richards-3, Richards-2, Richards-1, Endoscopy, Cardiac Catherization, East Tower-4, East Tower-3, and East Tower-2) and of 2 of 9 out-patient areas (930 Congress Street and 100 Campus Drive).

Findings:

Standard: §482.42(a)(1) Infection Control Program also known as A-0749 - Based on observations, interviews, and document reviews, the hospital failed to have a system to ensure the maintenance of a sanitary environment to prevent potential infections, failed to have a system to ensure that infection prvevention gowns were maintained in useable condition, and failed to have a system to monitor and ensure staff were utilizing the infection prevention gowns, gloves consistent with acceptable standards of practice. See A-0749 for details.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.

Based on observations and interviews, the facility failed to have a system in place to maintain an environment to control potential infections for patients on precautions and during medication administration on 3 of 7 survey days, and to ensure the maintenance of a sanitary environment to prevent potential infections in 21 of 29 in-patient care areas and 2 of 9 out-patient areas.

Findings:

1. On 2/19/19 at 2:30 PM, during tour of R-4, 2 surveyors and the Director of Professional Practice observed three clinical staff members in Patient Room 404, who were on precautions. All three staff members were wearing gowns; however, two staff members had not properly tied the back of their gowns, thus exposing their backs. At the time of the observation and in an interview with the Director of Professional Practices, the surveyors confirmed the finding.

2. On 2/20/19 at 10:17 AM, during tour of R-7, 2 surveyors and the Director of Professional Practice observed a Physician Assistant in a room with a patient who was on precautions; he/she had a gown on and did not tie the back of the gown, thus exposing his/her back. At the time of the observation, the surveyors confirmed the finding with the Director of Professional Practice.

3. On 2/21/19 at 9:15 AM, two surveyors observed a Registered Nurse (RN) administer medications to Patient Room #63 on Pavilion 6. The two surveyors observed the RN carry medications and a cup of water to the patient, with his/her finger submerged in the water in the cup. The surveyors intervened and the RN obtained a fresh cup of water. Additionally, the surveyors observed the RN don gloves to apply a lidocaine patch, he/she dropped the lidocaine patch on the floor while it was still in the packages, and with the same gloves on picked the package up off floor and applied the lidocaine package. Following the medication administration, the Registered Nurse was informed of the infection control concern. On 2/21/19 at 10:35 AM, in an interview with the Director of Pavilion 6 the surveyor informed him/her of the concern and confirmed the finding.

4. On 2/21/19 at 10:42 AM, signs were observed at the entrance of Room 10247 in SCU 4 which indicated "enteric precautions" and "DRO precautions".

Two surveyors observed a Certified Nursing Assistant (C.N.A.) in Room 1047 who had a yellow gown on. The gown was tied very loosely at the top and was not tied anywhere else. When the C.N.A. reached down to tie the garbage bag, the gown was sliding off the C.N.A.'s left shoulder down to her elbow area; thus exposing her shoulder and arm to the elbow. The C.N.A. continued on doing her work and did not attempt to retie the gown or pull the gown up over her left shoulder.

At 10:48 AM, the C.N.A. removed the gown just inside the door of the room. The gown was placed in a bag that was located inside the room and then she removed gloves from her hands and placed them into a different bag inside the room. She then walked halfway back into the room to the sink where she washed her hands, put a clean pair of gloves on, and then left the room taking the two bags to the dirty utility room.

The C.N.A. failed to utilize proper infection control practice when she failed to tie the gown securely around her and when she walked back to the sink without a gown on or gloves on.

5. On 2/25/19 at 1:06 PM the surveyor observed a C.N.A. enter room 412 which had a sign on the door that stated "DRO Precautions" without wearing gloves or a gown, despite them being readily available in a device hanging on the outside of the door to room 412. The C.N.A. exited the room at 1:09 PM carrying a patient tray and then stopped and re-entered the room stating, "Oops I forgot to reset the call light in the bathroom." The surveyor stopped the C.N.A. in the hallway and asked what the sign on the door to room 412 meant, the C.N.A. responded, "It means Drug Resistant Organism and I'm supposed to wear gloves and gown which I obviously didn't." This finding was discussed with the R-4 Charge Nurse on 2/25/19 at 1:45 who stated that she would follow up on this with the staff.

6. On 2/25/19 at 1:25 PM while conducting facility onservations, the surveyor was doning gloves and an infection prevention gown from the clean supplies outside of room 411 prior to entering the room. The surveyor removed 2 gowns from the clean and ready to use supply which were unusable, both gowns had knots tied in the top of the gown that would not allow it to pass over the surveyors head, and both gowns were missing one of the waist tie straps rending them unable to be tied appropriately. A Registered Nurse removed a clean and fully functiong infection prevention gown from a closet located in the hallway between rooms for the surveyor. The surveyor inquired if the infection prevention gowns being knotted and missing straps is a common occurance and the RN stated it was and that they set them aside and make the luandry staff aware of the issue and if they are really bad they just discard them in the trash. This finding was discussed with the Vice president of Nursing on 2/25/19.

7. On 2/25/19 at 1:36, the surveyor observed a Registered Nurse (RN) in room 412 wearing gloves and a yellow protective gown which was untied in the back so that it hung loosely at the RN's sides. The RN was observed with a computer on wheels charting station and she sat on the edge of footboard of a patient's bed in room 412 with her scrubs touching the bed as the protective gown was not tied in the back. The RN stood up and reached into her left front scrub pocket without changing her gloves and proceed to resume charting without ever changing the gloves that she wore into the room once. This finding was discussed with the R-4 Charge Nurse on 2/25/19 at 1:45 who stated that she would follow up on this with the staff.





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8. On 2/20/2019 at 11:20 AM, observed no air gap to be present in the food preparation sink drain in the Ingredient Control Room of the kitchen; therefore, creating on opportunity for the back flow of waste water into the food preparation sink. This observation was confirmed with the Director of Nutrition Services at the time of the observation.

9. A total of 19 ice machines were observed to be lacking air gaps; therefore, creating on opportunity for the back flow of waste water into the ice machine. The observations were as follows:

a. On 2/19/2019 at 2:15 PM, no functional air gap was observed on the drain line of the ice machine in Kitchenette Room B723. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

b. On 2/20/2019 at 10:00 AM, no functional air gap was on the drain line of the ice machine in Kitchenette Room B771. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

c. On 2/20/2019 at 10:30 AM, no functional air gap was observed on the drain line of the ice machine in the Critical Decision Unit of the Emergency Department. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

d. On 2/21/2019 at 9:35 AM, no functional air gap was observed on the drain line of the ice machine in Kitchenette 1, Room 614. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

e .On 2/21/2019 at 9:40 AM, no functional air gap was observed on the drain line of the ice machine in Kitchenette 2, Room 6024. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

f. On 2/21/2019 at 10:45 AM, no functional air gap was observed on the drain line of the ice machine East Tower, 1st Floor Kitchen Area. This finding was confirmed with the Facilities Manager, at the time of the observation.

g. On 2/21/2019 at 11:20 AM, no functional air gap was observed on the drain line of the ice machine in the Richards 9 Kitchenette, Room 9146. This finding was confirmed with the Facilities Manager, at the time of the observation.

h. On 2/21/2019 at 11:40 AM, no functional air gap was observed on the drain line of the ice machine in Kitchenette, Room 5033. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

i. On 2/21/2019 at 12:05 PM, no functional air gap was observed on the drain line of the ice machine in Kitchenette, Room 5022. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

j. On 2/21/2019 at 1:30 PM, no functional air gap was observed on the drain line of the ice machine in the Richards-9 Kitchenette, Room 9114. This finding was confirmed with the Facilities Manager, at the time of the observation.

k. On 2/21/2019 at 1:50 PM, no functional air gap was observed on the drain line of the ice machine in the Richards-7 Kitchenette, Room 7116. This finding was confirmed with the Facilities Manager, at the time of the observation.

l. On 2/21/2019 at 2:10 PM, no functional air gap was observed on the drain line of the ice machine in Med Area, Room 2025. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

m. On 2/22/2019 at 9:10 AM, no functional air gap was observed on the drain line of the ice machine in the Ambulatory Cardiac Care Unit Kitchenette. This finding was confirmed with the Facilities Manager, at the time of the observation.

n. On 2/22/2019 at 10:55 AM, no functional air gap was observed on the drain line of the ice machine in the Richards-6 Kitchenette, Room 6112. This finding was confirmed with the Mechanical/Electrical Manager, at the time of the observation.

o. On 2/25/2019 at 10:40 AM, no functional air gap was observed on the drain line of the ice machine in the Special Care Unit 3 Kitchenette. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

p. On 2/25/2019 at 11:45 AM, no functional air gap was observed on the drain line of the ice machine in the Special Care Unit 4 Kitchenette. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

q. On 2/25/2019 at 2:15 PM, no functional air gap was observed on the drain line of the ice machine in the Richards 5 Kitchenette. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

r. On 2/26/2019 at 9:25 AM, no functional air gap was observed on the drain line of the ice machine in the Richards-3, Intermediate Care Unit Kitchenette. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

s. On 2/26/2019 at 9:55 AM, no functional air gap was observed on the drain line of the ice machine in the Richards-2 Kitchenette. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

t. On 2/26/2019 at 11:00 AM, no functional air gap was observed on the drain line of the ice machine in the Radiology Area, 100 Campus Drive. This finding was confirmed with the Manager of Safety and Emergency Management, at the time of the observation.

u. Additionally, on 2/26/2019 at 11:55 AM, the surveyor was not able to determine if an air gap was present in the ice machine drain line due to it being enclosed, in the Kitchenette Room 121. The Director of Facilities stated that it could be assumed that no air gap was present.

10. On 2/19/2019 between 1:40 PM and 3:00 PM, the following was observed:

a. A tear in the seat of a chair, creating a surface that cannot be easily cleaned and sanitized, in the small waiting room (former pediatric waiting room). This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

b. A tear in the cover of a stretcher mattress, a surface that cannot be easily cleaned and sanitized, in the Critical Care Hallway across from room B711 in the Emergency Department. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

c. Dirt/debris accumulation on the bases of two soiled linen hamper carts in the Ambulance Bay of the Emergency Department. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

d. A tear in the seat of a chair, creating a surface that cannot be easily cleaned and sanitized, in Room K9, B173 in the Emergency Department. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

11. On 2/20/2019 between 9:30 AM and 3:15 PM, the following was observed:

a. A significant accumulation of dust on the uppermost horizontal surface of the closet doors in Rooms B187, B188, B191, B167, B178, B 119, and B120 of the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

b. A significant accumulation of dust on the uppermost horizontal surface of the dry erase board in Rooms B187, B188, B191, B167, B770, and B118 of the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

c. A significant accumulation of dust on the uppermost horizontal surface of the wall-hung picture in Rooms B192 and B770 of the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

d. A significant accumulation of dust on the uppermost horizontal surface of the light support arm in Rooms B192, B167, B168, B178, and B770 of the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

e. Cracked rubber feet, creating surfaces that cannot be easily cleaned or sanitized on a stool in B178 of the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

f. A significant accumulation of dust on the bed frame in Rooms B188 and on the on the uppermost horizontal surface of a wooden pamphlet holder in Room B167 In the Emergency Department. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

12. On 2/20/2019 between 9:40 AM and 3:00 PM, the following was observed:

a. Missing paint and/or damage to walls, creating uncleanable surfaces in Rooms 4833, 4740, and 3760 of the East Tower. These findings were confirmed with the Facilities Manager at the time of the observations.

b. Warn varnish or damage on wooden furniture arms/legs/trim creating surfaces that cannot be easily cleaned and sanitized, in Rooms 4841, 4835, 4704, 3839, 3728, 3748, 3752, 3760, 3712, and 3720 of the East Tower. These findings were confirmed, with the Facilities Manager at the time of the observations.

c. Unzippered clean linen carts, exposing the linens to contamination in the hallway, by Room 4720 and in Room 4832. These findings were confirmed with the Facilities Manager at the time of the observations.

d. Worn window gaskets/seals, creating a surface not easily cleaned and sanitized, in Rooms 3836, 3728, and 3760 of the East Tower. These findings were confirmed with the Facilities Manager at the time of the observations.

e. A corkboard, containing a porous surface that cannot be easily cleaned or sanitized, in the Public Bathroom in the hallway of the 2nd floor of the East Tower. This finding was confirmed with the Facilities Manager at the time of the observation.

f. A tear in the seat of the couch, creating a surface not easily cleaned and sanitized, in Room 2712 of the East Tower. This finding was confirmed with the Facilities Manager at the time of the observation.

13. On 2/21/2019 between 5:30 AM and 3:15 PM, the following was observed:

a. Tears in the seats of chairs and/or stools, creating surfaces not easily cleaned or sanitized in Operating Rooms (OR)s 1, 3, 6, and 22, Bean-5 Rooms 572 and 514, and in Bean-4 Room. 406. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

b. Corkboards, containing porous surfaces, not easily cleaned or sanitized in the Operating Work Room B075, in Bean-5 Rooms 554, 560, 563, and 576. These findings were confirmed, with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

c. Warn varnish or damage on shelves, trim, and/or wooden furniture arms/legs/trim creating surfaces that cannot be easily cleaned and sanitized in the Operating Work Room B075, in Bean-6 Room 660, in Bean-5 Rooms 542 and 572, and in Cardio-Thoracic Care Unit Rooms 1017 and 1019. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

d. Tape and/or tape residue, creating a surface not easily cleaned or sanitized on an arm board in OR 13 and on the operating table in OR 15. These findings were confirmed with the OR Director at the time of the observations.

e. Damage to the outside edges of the wooden doors, creating surfaces not easily cleaned or sanitized, in the entry of OR 20. This finding was confirmed with the OR Director at the time of the observation.

f. Missing paint and spots of rust, creating surfaces not easily cleaned or sanitized, on the base of linen carts in OR 22 and 24. These findings were confirmed with the OR Director at the time of the observations.

g. A peeling plastic layers of protective covering, creating surfaces not easily cleaned or sanitized, on tray carts in ORs 21 and 23. These findings were confirmed with the OR Director at the time of the observations.

h. Missing paint and spots of rust, creating surfaces not easily cleaned or sanitized, and on the bottom of the refrigerator door in Bean-6 Room 630. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

i. A significant accumulation of dust on the uppermost horizontal surface of the window frame in Bean-6 Rooms 632, 633, 635, 636, and 638. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

j. A significant accumulation of dust on the uppermost horizontal surface of the dry erase board in Bean-6 Rooms 638, 644, 653, 654, 657, and 659, in Bean-5 Rooms 542, 546, 550, 560, 563, 572, and 576, and Cardio-Thoracic Care Unit Room 1016 and of the patient wall-mounted light fixture in Cardio-Thoracic Care Unit Room 1015. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

k. A significant accumulation of dust in the bathroom exhaust vent in Bean-6 Rooms 644, 660, 661, and 662, in Bean-5 Rooms 550, 554, 560, 572, 576, and 5029. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

l. Cracks in the arm pads, creating surfaces not easily cleaned or sanitized, on 2 crutches in Bean-6, Equipment Room 2, Room 6026 and on 4 crutches in Bean-5, Soiled Linen Room 523. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

m. Damaged walls, creating surfaces not easily cleaned or sanitized, in Bean-6 Rooms 6086, 6087, 6088, 6082, ad 6083. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

n. Rusty shelving (holding patient supplies), creating surfaces not easily cleaned or sanitized, in the Environmental Services Room 5026. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

o. Dirt/debris accumulation on the bases of a soiled linen hamper cart in Bean-5 Room 568. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

p. Rust on the leg of a commode, creating a surface whichcannot be easily cleaned and sanitized, in the Post-Op Storage Room 27. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

14. On 2/21/2019 between 9:10 AM and 2:45 PM, the following was observed:

a. An unzippered clean laundry cart, potentially exposing clean linens to contamination in the East Tower 3rd floor patient hallway and in the hallway of the Richards-7 Cardiac Unit. These findings were confirmed with Facilitiy Manager at the time of the observations.

b. Worn/porous finish on wooden window shelves, cabinets, chairs, and/or refrigerator cabinets, creating surfaces which cannot be easily cleaned and sanitized in East Tower Rooms 2724, 2732, and 2819, in Richards-9 Rooms 907, 912, 921, 917, and 919, in Richards-7 Rooms 721, 710, 712, and 7153 as well as the hallway hand/bumper rails in the hallways of Richards-7. These findings were confirmed with Facilities Manager at the time of the observations.

c. Damaged walls/ missing paint, creating surfaces not easily cleaned or sanitized, in East Tower Rooms 2724 and 2732, in Richards-9 Rooms 922A, 917, and in the Medication Room, and in Richards-7 Room 721. These findings were confirmed with Facilities Manager at the time of the observations.

d. Tape/tape residue on counter or cabinet tops, creating surfaces not easily cleaned or sanitized, in East Tower Rooms 2724, 2730, and 2821. These findings were confirmed with Facilities Manager at the time of the observations.

e. A significant accumulation of dust on the uppermost horizontal surface of the refrigerator and ice machine in the Richards-9 Kitchenette Room 9146, of the patient lift rails in Richards-9 Rooms 921 and 917, and in the exhaust vents of Richards-9 Rooms 922A and 917 and in Richards-7 Rooms 721 and 720. These findings were confirmed with Facilities Manager at the time of the observations.

f. Corkboards, containing porous surfaces, not easily cleaned or sanitized, in Richards-9 Rooms 922, 921, 922A, 917, and 919. These findings were confirmed with Facilities Manager at the time of the observations.
Damaged bathroom doors, creating surfaces not easily cleaned and sanitized, in Richards-7 Rooms 721 and 720. These findings were confirmed with Facilities Manager at the time of the observations.

15. On 2/21/2019 at 10:20 AM, Surveyor 30938 observed a significant accumulation of dust on the uppermost horizontal surface of the patient lift mails in Richards-9 Room 922A. This finding was confirmed at the observation with the Nurse Manager.

16. On 2/22/2019 between 9:00 AM and 12:00 PM, the following was observed:

a. An unzippered clean laundry cart, potentially exposing clean linens to contamination in Richards 7 patient hallway near the Kitchenette and in the hallway by the East Tower Ground Floor Nurse's Station. These findings were confirmed with Facilities Manager at the time of the observations.

b. A significant accumulation of dust on the uppermost horizontal surface of the supply cabinets in Richards-8 Bays 7 and 6, and on the dry erase board in Bay 3. These findings were confirmed with Facilities Manager at the time of the observations.

c. A significant accumulation of dust on the uppermost horizontal surface of the window sill in he Richards-8 Critical Care Unit Waiting Room, on the patient lift rails in Richards-7 Rooms 714, Richards-6 Rooms 611, 614, 616, 620, and 621, on the dry erase boards in Richards-6 Rooms 603, 615, and 616, and in the bathroom exhaust vent of Richards-7 Rooms 714 and 716. These findings were confirmed with Mechanical/Electrical Manager at the time of the observations.

d. Worn/porous finish on wooden chairs and/or refrigerator cabinets, creating surfaces which cannot be easily cleaned and sanitized in Richards-7 Rooms 714 and 716, Richards-6 Rooms 601, 602, 603, 611, 616, and 621 and East Tower Ground Floor Rooms 1066 and 1074. These findings were confirmed with Mechanical/Electrical Manager at the time of the observations.

e. Rust on the wheel casters of the shower chair, creating a surface which cannot be easily cleaned and sanitized in the Richards-6 Bathroom Room 6137. This finding was confirmed with Mechanical/Electrical Manager at the time of the observation.

17. On 2/25/2019 between 10:15 AM and 3:20 PM, the following was observed:

a. Corkboards, containing porous surfaces, not easily cleaned or sanitized, in Special Care Unit-2 Rooms 1029, 1025, 1023, 1027, 1020, and 1026, Special Care Unit-3 Room1032, and in Special Care Unit-4 Rooms 1045, 1046, 1047, and 1049. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

b. A significant accumulation of dust in the exhaust vents of Special Care Unit 2 Rooms 1029 and 1025, of Richards Room-5 Rooms 503, 507, 511, 516, and 520, and of Richards-3 Room 305. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

c. A significant accumulation of dust on the uppermost horizontal surface of the dry erase boards in Special Care Unit-2 Rooms 1023, 1027, 1020, and 1026, Special Care Unit-4 Rooms 1045, 1047, and 1049, in Richards-5 Rooms 523, 525, 501, 504, 511, 514, and 520, and in Richards-4 Rooms 417, and 416, on the bed frame in Special Care Unit-4 Room 1049, and on the uppermost horizontal surface of the closet doors in in Richards-5 Room 501and Richards-4 Room 422, and on the privacy curtain support rod in Richards-5 Room 526. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

d. Cracks in the arm pads, creating surfaces not easily cleaned or sanitized, on 4 crutches in the Richards-5 Soiled Utility Room 5169. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

e. Tears in the seats of chairs, creating surfaces not easily cleaned or sanitized, in Richards-5 Rooms 514 and Richards-4 Room 406. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

f. Chipped paint and rust, creating surfaces not easily cleaned or sanitized, on the base of an intravenous (IV) pole, in Richards-5 Soiled utility Room 5110 and on the base of a linen cart in Richards 4 Room 406. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

18. On 2/25/2019 at 1:40 PM, Surveyor 30938 observed stained ceiling tiles, indicating a fluid leak and potentially creating a habitat for mold growth, in Room 1 (one tile) and Room 3 (2 tiles) at the Main Institute for Sleep and Breathing Disorders, 930 Congress Street, Portland. This finding was confirmed at the observation with the Outpatient Regulatory Compliance Specialist.

19. On 2/26/2019 between 7:45 AM and 3:15 PM, the following was observed:

a. Tears in the seats of chairs and/or stools, creating surfaces not easily cleaned or sanitized, in Interventional Radiology Room 1, Catherization Lab 6, Electrophysiology Room 9, Richards-3 Rooms 301, 301, and 325, In Richards-1 Rooms 108 and 111, and in Endoscopy Room 4417. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

b. Worn/porous or damaged finish on the wooden surface of stools cabinets, and/or the wooden parts of chairs, creating surfaces which cannot be easily cleaned and sanitized, in Catherization Lab 4 ("CPR box"), in Electrophysiology Room 9, in Richards-3 Room 308, in Richards-2 Room 212, and in the Richards-1 Shower Room 1156. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

c. Missing/chipped paint, creating surfaces not easily cleaned and sanitized, on the bases of the C-Arms in Catherization Labs 3, 4, 5, and 6. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

d. A significant accumulation of dust in the exhaust vents in Richards-3 Rooms 301, 302, 314, 315, and 316, in Richards-2 Rooms 216, 217, 225, 226, and 227, and in Richards-1 Room 124. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

e. A significant accumulation of dust on the uppermost horizontal surface of the closet doors in Richards-3 Rooms 301, 302, 314, 315, 316, and 324, in Richards-2 Room 212, and in Richards-1 Rooms105 and 110, of the dry erase boards in Richards-3 Rooms 301, 302, 304, 324, and 325, in Richards-2 Room 216, and in Richards-1 Room 112, of the patient lift rail in Richards -2 Rooms 216 and 226 and in Richards-1 Rooms 102, 111, 112, 116, 117, 119, 123A, and 123B. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

f. A significant accumulation of dust on the bed frames of Richards-1 Rooms 101 and 125. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

g. Strips of cork board mounted to the walls, made of a porous surface which cannot be easily cleaned or sanitized, in Richards-3 Rooms 301, 302, 324, and 325 and a corkboard, made of a porous surface which cannot be easily cleaned or sanitized, in the Endoscopy Clean Supply Room 4422. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

h. Tape/tape residue around the tops of bedside dressers, creating surfaces which cannot be easily cleaned and sanitized, in Richards-1 Rooms 108 and 111. These findings were confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observations.

i. Rust on the base of an IV pole, creating a surface which cannot be easily cleaned and sanitized, in Endoscopy Procedure Room 2, Room 4421. This finding was confirmed with the Director of Facilities and/or the Manager of Facilities, at the time of the observation.

Based on record review, policy review, and interview, it was determined that the facility failed to identify at an early stage of hospitalization, the likelihood the patient may suffer adverse health consequences upon discharge for 1 of 11 medical records reviewed. (Record #3).

Finding:

On February 20, 2019, at approximately 11:04 AM, 5 patient medical records were reviewed with the Manager of Care Coordination and Discharge Planning. During the record review, it was determined that there was no initial screening evaluation process documented in 1 of 5 medical records reviewed. (Record #3).

During review of the Care Management Discharge Planning Process Policy, it states that the Care Management patient assessments are to be conducted and documented within 24 business hours of admission.

On February 21, 2019 at 2:41 PM in an interview with the Manager of Care Coordination and Discharge Planning, the Manager acknowledged that there were gaps in their chart audits regarding Care Management performance in discharge planning assessments within 24 hours of admission.

On February 27, 2019 at approximately 2:00 PM, the Manager of Care Coordination and Discharge Planning provided a written Memorandum identifying the gaps and supporting documentation regarding Care Management for weekend staffing. (Dated February 21, 2019).

On February 25, 2019 at approximately 10:00 AM, during an interview with the legal guardian of Patient #65, the surveyor was informed that no one had been into the patient's room to discuss discharge planning or evaluate and discuss any need for post hospitalization medical care. Patient #65's guardian stated that the patient was transferred from another hospital 6 hours away and was admitted on 2/22/19. A review of the medical record conducted on February 25, 2019 at approximately 2:50 PM found no evidence of case management discharge assessment and planning within 24 hours as required by hospital policy. The medical record indicated that the first discharge planning/case management assessment occurred approximately 60 hours post admission. This finding was reviewed with the Registered Nurse with Clinical Informatics on February 25, 2019 at 3:00 PM.

Based on record review and interview it was determined that the facility failed to notify the Organ Procurement Organization (OPO) of imminent death within the prescribed time of one hour in 2 of 5 Organ, Tissue and Eye medical records reviewed.

Finding:

Maine Medical Center Institutional policy titled Organ and Tissue Donation stated, "The physician, designee, or registered nurse will report all deaths (except patients admitted with a severe neurological injury) to the New England Donor Services, no more that one hour after asystole."

On February 22, 2019 at approximately 2 PM, death records 1 - 5 were reviewed with the Organ, Tissue and Eye (OTE) Medical Center representative. Appropriate notification (within one hour) could not be found in 2 of 5 patient death records. In record #2, the death notification was documented at 2 hours. Record #3 revealed that no notification was found in the patient's medical record.

On February 22, 2019 at approximately 2 PM, the Organ, Tissue, and Eye (OTE) Medical Center representative confirmed that 2 of 5 records did not meet the appropriate one hour death notification to the Organ Procurement Organization.