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Based on review of policies and interviews with key staff on October 4, 2011, it was determined that the facility failed to meet the Federal Condition of Participation: Patient ' s Rights, 482.13(e)(ii) which requires that physicians and licensed independent practitioners training requirements must be specified in the hospital restraint policy. At a minimum, physicians and other licensed independent practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of the hospital policy regarding the use of restraint or seclusion.

Findings include:

1. A review of the Department of Nursing policy titled, ' RESTRAINTS ' stated, " 4. Education: 1. Staff must be trained and able to demonstrate competency in the application of restraints, monitoring, assessment, and providing care for a patient in restraint. Before performing any of the actions specified in this paragraph; as part of orientation; and subsequently annually for all staff who have direct patient care responsibilities. "

2. During and interview with the Director of Ancillary Services & Regulatory Affairs on October 4, 2011, she stated that the hospital restraint policy did not include the requirement for physicians and independent licensed practitioners to have a working knowledge of the hospital policy regarding restraints or seclusion.

3. Seven (7) credential files were reviewed on October 5, 2011 and there was no documentation that physicians and licensed independent practitioners had a working knowledge of the hospital restraint policies.

4. The hospital was in the process of revising the restraint policy during the survey process.

Based on review of information provided, observations and interviews with key personnel, on October 5, 2011, it was determined that the facility failed to ensure the facility was constructed, arranged, and maintained to ensure safety of patients.

Findings include:

1. During tour of the facility the following items were observed:
a. In LDRP [Labor and Delivery Recovery Post Partum], it was noted that there were various items located under the sink.
b. In the Respiratory Therapy room, it was noted that there were various items located under two sinks.
c. In the Laboratory, it was noted that there were various items located under the sink.
d. In the Chapel, it was noted that there were ceiling tiles which were water stained.
e. In the Radiology changing room, it was noted that there were ceiling tiles which were water stained.
f. In the Operating Room, it was noted that the base of the wall, in room #4, was damaged.
g. In the Operating Room, it was noted that the entry double doors, were chipped.
h. In the doctor ' s changing area, of the Operating Room, it was noted that there were floor tiles broken under the urinal.
i. In the Emergency Department, there were two ceiling tiles which were water stained.
j. In the Emergency Department, in Exam Room III, there was an exposed live wire.
k. In the mechanical room, it was noted that there was a plumbing auger resting on a box of clean air filters.

2. Items a, b, c, j and k were corrected while the surveyor was on site.

3. These findings were confirmed by the Maintenance Manager on October 5, 2011.

Based on review of information provided, observation and interview with the Emergency Department Manager, on October 4, 2011, it was determined that the hospital failed to ensure that drugs and biological's were appropriately stored in the Emergency exam rooms, and Central Storage.

Findings include:

1. During tour of the Emergency Department, the following items were noted to be expired or lacking an expiration date.
a. Exam Room III, the blood tubes for collection of umbilical cord core blood, in the emergency delivery pack, had an expiration date of August 2005.
b. In the Central Storage room, two blood culture bottles had expired. One expired on May 2010, and the other expired on October 2010.
c. In the Central Storage room, two 4 ounce bottles of Betadine, contained a label which indicated discard after 1 year, but lacked an opened date.
d. In the Central Storage room, one 16 ounce bottle of Betadine Solution, which indicated it was opened on August 2010, and had a label which indicated discard after 1 year.
e. In the Central Storage room, one 16 ounce bottle of Betadine Scrub, which indicated discard after 1 year, but which lacked a date opened.
f. In the Dirty Utility room, it was observed that there was a bottle of Renuzyme Foam Spray, Instrument cleanser which had a manufactures expiration date of September 2011.

2. These findings were confirmed by the Emergency Department Nurse Manager on October 4, 2011, at 12:15 PM.

3. During tour of the Labor and Delivery Room, it was observed that laboratory Vacutainer tubes had an expiration date of August 2010.

4. This finding was confirmed by the Labor Delivery Recovery Post Partum Nurse Manager on October 5, 2011.

5. The above out dated items were removed from circulation at the time of the observations.

Based on a review of anesthesia policies, review of anesthesia forms and interviews with the Chief Anesthetist, a Certified Registered Nurse Anesthetist (CRNA) on October 5, 2011, it was determined that there was no documented evidence that in those cases in which a CRNA administers the anesthesia, the anesthetist (CRNA) at the hospital were under the supervision of the operating practitioner.

Findings include:


1. During an interview on October 5, 2011, the Chief Anesthetist, (a CRNA) described the anesthesia forms as having two parts - the first contained the anesthesia plan and the reverse contained the anesthesia record. The Chief Anesthetist stated that the anesthesia plan was completed by the CRNA prior to surgery, and signed by the surgeon.
2. The State of Maine Board of Nursing Rules and Regulations Chapter 8, C, (3) states: " adjustments and corrective actions as indicated. For aspects of anesthesia practice that require execution of the medical regimen, the certified registered nurse anesthetist shall be responsible and accountable to a physician or dentist. Without limitation, coordination and appropriate communication shall be deemed to have occurred if the prescribing physician or dentist shall have signed the patient's anesthesia record."
3. The Chief Anesthetist further described the anesthesia plan as a general description of the technique to be used, such as, " general anesthesia, or MAC (monitored anesthesia care), but did not necessarily contain the medications or doses to be used during the surgery. It also did not list adjunct medications to be used, nor did it list medications, doses or route of administration that may have been administered in the operating room that were not originally part of the plan.
4. The Chief Anesthetist confirmed that the anesthesia record was completed by the CRNA in the operating room during the procedure. The medications administered during the operative procedure, their dose, route of administration, and any adjuncts used, were recorded on the anesthesia record.
5. The Chief Anesthetist further confirmed that there were physician signatures on the pre-anesthesia record, but no documentation of physician authentication on the anesthesia record.