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Based on observations, interviews, and record review, the hospital failed to ensure that non-medical electrical devices had been inspected for electrical safety in 4 of 12 hospital areas (Labor and Delivery, Laboratory, Radiology, and Medical/Surgical Unit).

Findings:

The Lincoln Health -POLICY: Safety Management: Electrical Safety Plan, POLICY #: SM.09.8065.512 indicated the following:

C. Facility Owned Non-Medical Equipment:

1. Facility owned non-medical equipment will receive an initial electrical safety check provided by the Maintenance Department. In addition, non-medical equipment will be monitored for physical integrity by staff during their department specific surveillance rounds and during Environment of Care (EOC) Committee Safety & Quality Walk Arounds.

2. Equipment will be labeled with an inspection sticker that will include date of inspection, date of re-inspection (if applicable) and the inspecting individual's initials.

D. Personal Electrical Devices:

1. Personal electrical devices (i.e., shavers, TV sets, lamps, blow dryers, fans, radios, scanners, etc.) will receive an initial electrical safety check provided by the Maintenance Department. User department personnel are responsible to check periodically for physical integrity (i.e., frayed cords, damaged plugs, etc.) and report any concerns to the Maintenance Department."

On 1/14/19, electrical devices without stickers identifying that they had been inspected for electrical safety were observed as follows:

a. At 1:40 PM, a floor fan in the Pediatric room of the Wellness/Rehabilitation Area.

b. At 2:10 PM, table fans in Rooms #304 and #302 of Labor and Delivery area.

c. At 3:10 PM, a table fan in the Laboratory.

On 1/15/19, electrical devices without stickers identifying that they had been inspected for electrical safety were observed as follows:

a. At 7:35 AM, a floor lamp in the Mammography Room of Radiology.

b. Between 8:30 AM and 9:00 AM, a table lamp in the Supply Room #213 in the Medical/Surgical area and a table fan in the Medical/Surgical area at the Nurses' Station.

The above findings were confirmed with the Director of Operations at the time of the observations.

Based on record reviews and interviews, the hospital failed to provide evidence that the temperature in the operating room (OR) had been maintained while in use according to acceptable professional standards.

Findings:

Lincoln Health Damariscotta, Maine Policy Number OR.05.6220.082 indicated "Temperature will be maintained between 68 degrees Fahrenheit and 75 degrees Fahrenheit within each operating room."

A review of the November 2018, December 2018, and January 1 - 16, 2019 records of OR temperatures indicated that 83 of 160 (52%) of recorded temperatures were either out of range or unreadable.

On 1/16/19 at 10:30 AM, the Clinical Supervisor of the Surgical Suite stated that she records the OR temperatures in the morning when she first comes in, prior to any of the cases. She stated that the temperatures on their records are not the temperatures that the ORs are held at during use.

On 1/16/19 at 11:55 AM, the Nurse Manager of Surgical Services confirmed that they had a problem with recording the necessary OR temperatures.

Based on observations and interviews, the hospital failed to have a system to ensure an ice machine had an air gap to prevent backflow of waste water in 2 of 4 ice machines (Medical/Surgical & Intensive Care Unit) and to ensure surfaces were maintained to ensure sanitation for 7 of 12 hospital areas (Rehabilitation/Wellness. Radiology, Surgical Services, Cardiopulmonary, Medical/Surgical Unit, Emergency Services, & Intensive Care Unit).

Findings:

1. On 1/1/2019, at approximately 8:50 AM, in the kitchenette of the Medical/Surgical Unit, and at approximately 9:10 AM, on the Intensive Care Unit, ice machines were observed and were noted not to have an adequate air gap. An air gap is required to ensure that sewer waste does not back up through the drainage pipe, of the ice machine, into the ice machine; thus, contaminating the ice. These findings were confirmed with the Director of Operations (DO) at the time of the observations.

2. On 1/14/19, non-intact surfaces, creating surfaces which could not be easily cleaned and sanitized, were observed as follows:

a. At 1:50 PM, a cracked vinyl covering with tape patches on positioning wedge in the Physical Therapy Gym.

b. At 2:30 PM, a cracked arm pad on a crutch in the third floor hallway storage area.

c. At 3:15 PM, a torn and open corner on the vinyl covering of a positioning wedge in the Computed Tomography Room of Radiology.

The above findings were were confirmed with the DO at the time of the observations.

3. On 1/15/19, non-intact surfaces, creating surfaces which could not be easily cleaned and sanitized, were observed as follows:

a. At 7:05 AM, a frayed edge on a positioning wedge in the "Pippi Long Closet" Surgical Services' supply room.

b. At 7:20 AM, a damaged window sill with deep cracks in a treatment room of the Wellness/Rehabilitation area.

c. At 7:30 AM, a torn seat cover on a stool and peeling tape wrapped around the bottom of the front legs of a walker in X-Ray Room #2.

d. At 7:45 AM, worn finish on the wooden arms on a chair in the Stress Test Room of Cardiopulmonary.

e. Between 8:30 AM and 9:00 AM, worn finish on the arms of a chair in the Swing Activity Room of Medical/Surgical area, a punctured arm pad on a quad cane in Supply Room #213 of Medical/Surgical area, and a worn, cracked arm pad on a crutch in Supply Room #213 of Medical/Surgical area.

The above findings were confirmed with the DO at the time of the observations.

4. On 1/15/19, rusty surfaces, creating surfaces which could not be easily cleaned and sanitized were observed as follows:

a. At 6:55 AM, on the base of the doctor's stool and on the roller holder mounted on wall to right of door in Operating Room #3.

b. Between 7:50 AM and 9:00 AM, on the wheel casters of intravenous (IV) poles in Critical Care Room #2 of the Emergency Department (ED), in Room #4 of the Ambulatory Care Unit (2 IV poles), and in the Supply Room #213 of the Medical/Surgical area.

The above findings were confirmed with the DO at the time of the observations.

5. On 1/15/2019, stained ceiling tiles, indicating water leakage, were observed as follows:

a. At 7:25 AM, with a gray fuzzy substance hanging from it, in X-Ray Room #1.

b. At 8:03 AM, in Room #4 of the ED.

c. At 9:10 AM, in the medication room of the Intensive Care Unit.

These stained ceiling tiles created a possible habitat for mold growth.

The above findings were confirmed with the DO at the time of the observations.

Based on observation and interview, the hospital failed to ensure confidentiality of clinical records on viewable imaging screen in the Mammogram Department of Radiology Services.

Finding:

On 1/15/19 at 8:50 AM, the surveyor and Director of Radiology observed two computer imaging terminals in the waiting area of the Mammogram Department that were viewable by unauthorized personnel coming out of the changing area.

The surveyor requested the Director of Radiology Services access a patient record on one of the imaging terminals. The surveyor stood outside the patient changing area and was able to view the patient's name, demographic information, and mammogram image.

This finding was confirmed with the Director of Radiology Services at the time of the observation.