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Based on record review and interview with key personnel on May 28, 2014, it was determined that the facility failed to assure that patients were given their rights in advance of treatment for three (3) of thirty (30) sampled patient records (Record X, Z, BB).

Findings include:

1. Patient Record X contained a copy of the Inpatient rights of recipients of mental health services indicating that the patient had acknowledged seeing a summary of his/her rights as a recipient of inpatient services. The form, dated May 23, 2014, lacked acknowledgement of receipt of a copy of their rights.

2. Patient Record Z contained a copy of the notice of patient rights indicating that the patient had received a copy of their rights. The form, dated May 25, 2014 lacked a signature to indicate that the patient had received a copy of their rights.

3. Patient Record BB contained a copy of the notice of patient rights indicating that the patient had received a copy of their rights. The form, dated May 23, 2014, lacked a signature to indicate that the patient had received a copy of their rights.

4. The above findings were confirmed in an interview with the Quality consultant on May 28, 2014 at approximately 4:15 PM.

Based on observations and interviews with key personnel on May 28 and 29, 2014, it was determined that the facility failed to assure confidentiality of medical records in the facility.

Findings include:

1. During the environmental tour of the medical records room on May 29, 2014 at approximately 11:00 AM, the Director of Health Information was asked who did the cleaning and when. She responded that it was done by the environmental staff after hours, and that there were no medical record staff in the rooms at the time of cleaning. Three rooms with medical records were observed as being unlocked and the door, latch bolt, was taped in the open position.

2. The above finding was confirmed that, "the rooms with the records are not locked when they (environmental services) are around", by the Director of Health Information on May 29, 2014 at approximately 11:00 AM.

3. During the environmental tour of the Urology Clinic on May 29, 2014 at approximately 2:00 PM, records were observed in the office area, and when asked about cleaning, the surveyor was told that environmental services cleaned the clinic around 11:00 PM, when there were no clinic staff in the clinic.

4. The above finding was confirmed by the Vice President of Physician Services on May 29, 2014, at 2:00 PM.

5. Please see Tag A-0441 for additional information regarding confidentiality of patients medical records.

Based on review of policies and procedures, review of staff training, and interviews with key staff on May 28-29, 2014, it was determined that the facility failed to assure that physicians and licensed independent practitioners (LIP) authorized to order restraints, received training on restraint use as required by hospital policy.

Findings include:

1. Hospital Policy #6011-083, "Restraint Use" states the following;
a) "Staff Competency
i) Education and training shall be provided to staff directly involved in the implementation of restraint as part of initial orientation and periodically, as a competency every 24 months.
ii) This group shall include RNs, MDs, Dos, LIPs, mental health technicians ..."

2. During an interview with the Chief Medical Officer on May 28, 2014 at approximately 4:30 PM, he stated that he did not have documentation indicating that physician and LIPs authorized to order restraints, had a working knowledge of the hospital's restraint and seclusion policies.

3. During an interview with the Chief Medical Officer and Director of Quality, on May 29, 2014 at approximately 9:30 AM, both individuals confirmed that the hospital did not have documentation of training records indicating that the physicians and LIPs had a working knowledge of the hospital's restraint and seclusion policies, or had received the required training mandated by hospital policy.

Based on document review and interview with key personnel on May 29-30, 2014, it was determined that the hospital failed to assure that the staff were trained in the application of restraints.

Findings include:

1. The "Restraint Use" policy states,"Education and training shall be provided to staff directly involved in the implementation of restraints as part of initial orientation and periodically, as a competency every 24 months".

2. A review the personnel file of a Registered Nurse employed on July 5, 2011, who works on the Medical-Surgical Unit where restraints are utilized, was conducted. The file failed to contain evidence that the nurse had completed restraint training.

3. This was confirmed during an interview with the Director of Human Resources on May 29, 2014, at 5:30 PM. He stated, "It doesn't look like she was trained, but we are still looking for the documentation..."

Based on tours of the facility and interviews with key staff on May 28, 2014, it was determined that the facility failed to ensure the confidentiality of patient's medical records.

Findings include:

1. During a tour of the PREP area on May 28, 2014, at approximately 10:10 AM, a chart cart was observed blocking the doorway of the last office. This cart contained many medical records for surgeries to be performed in the next few days. There was a bathroom near this room. Names of patients could be read on the chart folders.

2. When the Clinical Coordinator was interviewed during the tour on May 28, 2014, at 10:20 AM, she stated that she could not guarantee that there were eyes on those medical records 100% of the time. (The Clinical Coordinator moved the chart cart to a room that would lock)

3. During a tour of the Cancer Care Center on May 28, 2014, at approximately 11 AM, charts were observed in a small room with windows and the door was open. Names of patients could be read. There was a bathroom near by. The staff could not guarantee that the charts were observed 100% of the time (The door was closed and locked immediately).

4. These findings were confirmed by the Chief Operating Officer and the Director Facility and Support Services during these tours, with the surveyor on May 28, 2014 at approximately 11:30 AM.

Based on record review and interview with key personnel on May 28, 2014, it was determined that the facility lacked evidence that the physical exams were signed for five (5) of thirty (30) sampled patients, (Records BB, EE, GG, II, and AAA).

Findings include:

1. Patient Record BB, admitted on May 23, 2014, contained a history and physical dated May 23, 2014, which lacked a signature.

2. Patient Record EE, admitted on May 18, 2014, contained a history and physical dated May 18, 2014, which lacked a signature.

3. Patient Record GG, admitted on May 25, 2014, contained a history and physical dated May 25, 2014, which lacked a signature.

4. Patient Record II, admitted on May 24, 2014, contained a history and physical dated May 23, 2014, which lacked a signature.

5. Patient Record AAA, admitted on May 26, 2014, contained a history and physical dated May 26, 2014, which lacked a signature.

6. The above findings were confirmed by the Director of Nursing on May 29, 2014 at approximately 1:30 PM.

Based on record review and interview with key personnel on May 28, 2014, it was determined that the facility failed to assure that a discharge summary was included in a medical record within thirty days of having been discharged, for one (1) of six (6) closed records (Record HHH).

Findings include:

1. Patient Record HHH, who was discharged on April 19, 2014, lacked evidence of a discharge summary with the outcome, disposition care, and follow-up expected, completed within thirty days of discharge and in the medical record.

2. This finding was confirmed in an interview with the Quality Consultant on May 28, 2014 at approximately 4:15 PM.

Based on a tour of the facility, review of policies and procedures and interviews with key staff on May 27-29, 2014, it was determined that the facility failed to assure that expired medications were removed from the inventory maintained in the treatment areas.

The findings include:

1. During a tour of Outpatient Practice, Pen Bay-Internal Medicine, on May 29, 2014, the following expired medications were observed: One (1) diphenhydramine 4 ounce bottle, expired "5-13"; three (3) multi-dose bottles 81 mg Aspirin, expired "1-14"; one (1) tube Glucose 15 37.5 grams, expired "7-30-13"; one (1) bottle nitroglycerine lingual spray, expired "Sept 2013"; one (1) bottle diphenhydramine 50 mg/ml, expired "11-2013"; one (1) bottle nitroglycerine lingual spray, expired "Dec 2012"; and two (2) boxes ammonia inhalants, expired "April 2013"

2. These findings were confirmed by the Vice President of Physician services on May 29, 2014 at approximately 1130 AM.

3. During tours of the Emergency Department on May 27-29, 2014 the following expired and opened/unlabeled vials/containers of medications were observed.

a. Room 1: One (1) multi-dose bottle Hydrogen Peroxide, 8 oz., partially used and not dated when opened.

b. Room 2: One (1) multi-dose bottle Betadine Solution, 2 oz., partially used and not dated when opened; two (2) multi-dose tube Nitrobid 2% paste, 30 gram, partially used and not dated when opened; two (2) 500 ml bags 10% Dextrose solution, expired "1 Aug 2012", and one (1) 250 ml bag 0.9% Saline Solution, expired "1 Feb 2014".

c. Medication (Pyxxis Room: One (1) multi-dose bottle Gebauer's Pain Ease 3.5 oz. spray, expired "3-14"; one (1) multi-dose bottle Gebauer's Ethyl Chloride 3.5 oz. spray, expired "8- 12"; Two (2) multi-dose vials 1% Lidocaine 10 mg/ml, partially used and not dated when opened; and one (1) multi-dose vial Bupivacaine 0.5% 5 mg/ml, partially used and not dated when opened.

d. Minor treatment room, 1410C: One (1) multi-dose bottle Betadine Solution, 4 oz., partially used and not dated when opened; one (1) multi-dose bottle Betadine Solution, 2 oz., partially used and not dated when opened; and one (1) multi-dose bottle tincture of benzoin, 2 oz., partially used and not dated when opened

4. These findings were confirmed by the Nurse Manager, Emergency Department, on May 27, 2014 at approximately 10:30 AM, and May 29, at approximately 10:00 AM.

5. Pharmacy Policy #70710-089, "Use of Multiple Dose Vials (MDVs)" states; "The beyond-use date of an opened or entered ...shall be 28 days, unless otherwise specified by the manufacturer. Single dose vials, those agents without preservatives, are not dated and are for single use only." "The pharmacy department shall verify that MDVs are stored and labeled correctly when inspecting medication storage areas."

6. Pharmacy Policy #7070-010, "Inspection of Patient Care Units" states; "Patient care units where legend products, i.e., Medications ...are inspected on a monthly basis." "Areas to be inspected include ...ED [Emergency Department]."

Based on review of medical records, review of policies and procedures and interviews with key staff on May 29, 2014, it was determined that the facility failed to document the notification of the attending physician immediately in the case of a medication error in one (1) of five (5) medical records. (RECORD: ZZ)

Findings include:

1. Penobscot Bay Medical Center policy titled 'Medication Error' stated, "POLICY PURPOSE: To assure quality care of the patient involved and to ensure appropriate documentation. PROCEDURE: Upon discovery of a medication error: 3. Notify physician. All medication errors should be brought to the attention of the physician who ordered the medication or the physician covering for that physician."

2. Record ZZ was reviewed on May 29, 2014. There was no documented evidence of notification of the physician or of the error itself.

3. This finding was confirmed by the Clinical Risk Manager on May 29, 2014 at approximately 1:00 PM.

Based on review of policies and procedures, review of information provided, tours of the facility and outpatient areas and interviews with key staff May 27-29, 2014, it was determined that the facility failed to ensure that the overall condition of the physical plant was maintained in a manner that the safety and well-being of patients was assured at all times.

Findings include:

1. On May 28, 2014, from 8:30 AM until 4:30 PM, and on May 29, 2014, from 8:00 AM until 2:00 PM, tours of the facility and the outpatient areas were conducted. The tours revealed the following:

a. Podiatry Clinic - Exam Room 3 had a wall with that was scratched and sheetrock was exposed.

b. Public Restrooms in the Physicians Building - 1st restroom had un-grouted tile cove molding and sheetrock split at the corner near the door with visible rust and 2nd restroom had sheetrock exposed due to dings in the walls.

c. Obstetrical Unit - Soiled Utility Room had many scratches and dings in the wall with sheetrock exposed; Room 1112 had chipped formica around the sink; Room 1111 had a large rocking chair with finish all scratched and bare wood exposed; Room 1118 had walls that were streaked with Purcell and there were places that the grout was missing around the sink; Room 119 had a shower enclosure that was chipped and cracked, chipped formica around the sink and missing grout around the sink; Room 1121 had missing grout around the sink and walls streaked with Purcell; Family Room had two stained ceiling tiles and walls streaked with Purcell; Room 1124 had grout missing around the sink, a chipped and cracked shower enclosure, walls streaked with Purcell, unglued wood molding around the heater and marble bed stops that were cracked; Room 1126 had missing grout around the sink and walls streaked with Purell; Storage Closet had many boxes stored directly on the floor (these were subsequently removed).

d. Cancer Care Center - Room 1191 was missing cove molding on one wall and the room was dirty; and Room 1188 had a bottle of odor eliminator under the sink (removed then).

e. Infusion Clinic - Room 1137 had an entry door that was chipped and the area around the Purell dispenser had not been repainted; and Room 1133 had four holes in the walls made with wall anchors and other placed on the walls were scuffed as well as the area around the Purell dispenser was not repainted.

2. All of the above findings were confirmed by the Chief Operating Officer and the Director Facility and Support Services while on tours with the surveyor on May 27-May 29, 2014.

3. During an interview with the Director, Facility and Support Services on May 28, 2014, at approximately 2:00 PM, he stated that the facility did not have a Preventive Maintenance policy that spoke to routine maintenance of the hospital or the outpatient areas. The current policy only addressed work orders.

4. A tour of the outpatient areas was conducted by a surveyor on May 28, 2014, with the Clinical Care Manager and the Assistant Director of Facilities.

a. At 8:30 AM, a tour of PBMC Outpatient Psychiatry was performed. A stained tile ceiling tile was observed near the alternate exit door.

b. At 9:30 AM, a tour of Pen Bay Pediatrics at 7 Madelyn Lane in Rockport was performed. Damaged walls were observed behind the treatment tables in the Lobster Room, the Crab Room, the Shark Room, the Octopus Room, the Dolphin Room, and the Angel Fish Room and by the trash bins in the Shark Room, Dolphin Room and the Angel Fish Room, creating uncleanable surfaces. Additionally significant dust was observed on all door frames in the Lobster Room, the Crab Room, the Shark Room, the Octopus Room, the Dolphin Room, and the Angel Fish Room.

c. At 10:35 AM, a tour of the Center for Sleep Medicine at 7 Madelyn Lane in Rockport was performed. A crack in the wall on one side of the reception window was observed. In the Soiled Holding Room 3 empty boxes were observed on the floor. Significant dust was observed in the ceiling exhaust vent in the bathroom of Room 103.

d. At 10:55 AM, a tour of Mid-Coast Speech/Hearing/Occupational Therapy at 7 Madelyn Lane in Rockport was performed. Large, unsealed gaps between floor tiles were found near the wall to the right of the door in the public bathroom in the waiting area. The V & G/ENG room was observed to have many reddish stains on the floor. In the rehabilitation room the chalkboard was observed to have significant dust of the top of the frame and a crack was observed in the wall over the door to the storage room. In the hallway outside of the rehabilitation room, significant dust was observed in the ceiling vent. In the Heritage Room damage to the wall near an electrical outlet was observed.

e. At 11:30 AM, a tour of Pen Bay Specialty Clinic at 731 Commercial Street in Rockport was performed. The Diabetes Counseling office was observed to have cracked floor tiles. The hallway was observed to have large, unsealed gaps in the floor tiles.

f. At 12:05 PM, a tour of Dr. Robert Merrill's Practice at 821 Commercial Street, Suite 1 in Rockport was performed. In Exam Room 3 significant dust was observed on the Otis-scope base and the top of the door frame. In the patient bathroom a non-functioning light bulb and a ceiling exhaust vent with significant dust were observed.

g. At 1:35 PM, a tour of Pen Bay Women's Health at 3 Glen Cove Drive, Suite 1, in Rockport was performed. In Room 16 the baseboard and the bottom of a cabinet were observed to be damaged, creating an un-cleanable surface. In Room 11 the wall behind the exam table were observed to be damaged. In the Medication Room 2 stained ceiling tiles were observed. Unsealed gaps in the floor tiles were observed in the bathroom near the "Green Wal " and in the bathroom near Room 38. Unsealed cracks in the floor tiles were observed across the floor in Room 24 and in Room 29.

h. At 2:30 PM, a tour of Pen Bay Neurology at 4 Glen Cove Drive, Suite 102, in Rockport was performed. Floor tiles with large unsealed spaces between them were observed in the bathroom.

i. At 2:40 PM, a tour of Pen Bay Surgery & Wound healing Center at 4 Glen Cove Drive, Suite 103, in Rockport was performed. Room 3 was observed to have damaged walls.

j. These findings were confirmed with the Clinical Care Manger and the Assistant Director of Facilities on May 28, 2014 at 3:00 PM.

5. A tour of the Operating Room (OR) area was conducted by two (2) surveyors on May 28, 2014, with the Director of Surgical Services and the Assistant Director of Facilities at 3:30 PM.

a. The Holding Room area was observed to have holes in the wall and chipped wall corners near the sink.

b. The wooden nurses station counter was observed to be worn so that the surface was porous, creating an un-cleanable surface.

c. The Formica corners at the corners and ends of the nurse's station were not intact.

d. In Operating Room 1, an obstetrical cart was observed with many areas of tape residue creating an un-cleanable surface.

e. In the corridor outside of Operating 4 the corner of the wall was observed to be missing the corner coving.

f. An opened, partially empty Intravenous antibiotic bag was observed hanging from an Intravenous pole in Operating Room 4. In an interview with the Director of Surgical Services om at approximately On May 28, 2014 at approximately 3:40 PM, she stated that the room had been cleaned and had been prepped to be ready for the next day's surgical case.

g. In Operating Room 4, a wall-mounted x-ray film viewer light box was observed to have significant amounts of tape residue.

h. The corridor outside of Operating Room 4 was observed to have 2 areas where the base coving was either peeling off or missing from the wall.

i. The equipment storage area near Operating Room 4 was observed to have a damaged wall.

j. The counter in the endoscopy recovery area was observed to have missing areas of Formica, exposing an un-cleanable surface.

k. The patient snacks refrigerator in the endoscopy recovery room was observed to have a cleaning chart posted for the year. The chart indicating the refrigerator was to be cleaned each month and initialed by the individual who cleaned it. No areas on the form had been initialed. The refrigerator was observed to be soiled.

l. The door to procedure Room 1 was observed to be damaged.

m. These findings were confirmed with the Director of Surgical Services and the Assistant Director of Facilities on May 28, 2014 at approximately 4:30 PM.

6. On May 29, 2014, a tour of outpatient areas was conducted by a surveyor with
Clinical Care Manager and the Assistant Director of Facilities.

a. At 8:40 AM, a tour of Pen Bay Internal Medicine, 4 Glen Cove Drive, Suite 202 in Rockport was performed. In Exam Room 3 a dirty exhaust vent was observed. In Exam Room 4, a stain was observed under the sink. In a Storage closet a cardboard box was observed stored on the floor. In Exam Room 9 the Formica on the base of the cabinet was observed to be broken and a wall was observed to have damage. In the laboratory, the ceiling light was observed to have numerous dead flies. In the Medicine Alcove, a medicine cabinet was observed to have a broken lock. Between Exam Rooms 10 and 11 there was a crack observed in the wall. In Exam Room 11 and 14 there was damage observed to the walls. In Room #14 a deposit of an unknown substance was observed adhered to the upper surface of the exam table pad. Many exam rooms inspected (Exam Rooms 3, 4, 9, 11, 14, and 18) were found to have significant dust on the upper door frames.

b. These findings were confirmed with the Director of Surgical Services and the Assistant Director of Facilities on May 29, 2104 at approximately 9:20 AM.

7. On May 29, 2014, a tour of outpatient areas conducted by a surveyor continued with the Assistant Director of Facilities.

a. At 9:25 AM, a tour of Pen Bay Rehabilitation Services at 4 Glen Cove Drive in Rockport was continued. In the public rest room an exhaust vent with a significant amount of dust was observed. Damaged walls were observed in Treatment Room 6, 4, and 3.

b. At 9:45 AM, a tour of Health Connections at 6 Glen Cove Drive in Rockport was performed. In Room 1410C, a damaged wall was observed near a trash receptacle. A bathroom contained a cabinet that was observed to be missing paint.

c. These findings were confirmed with the Assistant Director of Facilities on May 29, 2014 at 9:50 AM.

8. On May 29, 2014, at 10:00 AM, a tour of inpatient Radiology was conducted by a surveyor with the Assistant Director of Facilities.

a. Damaged floor tiles were observed in the Mammography area, in the Nuclear Medicine area, in X-Ray Room 2, X-Ray Room 3, and X-Ray Room 4.

b. Unsealed gaps between floor tiles were observed in X-Ray Room 2 and in the hallway outside that room.

c. Unsealed gaps in floor tiles and unsealed screws into these tiles were observed in X-Ray Room 4.

d. A cardboard box was observed stored on the floor in the housekeeping closet.

e. The door to the hallway exiting X-Ray Room 3 and the door to Room 1238 were damaged.

f. Broken, missing Formica was observed at the nursing area.

g. Unpainted, patched walls were observed in the Ultrasound Waiting Area.

h. These findings were confirmed with the Assistant Director of Facilities on May 29, 2014 at 10:40 AM.

9. On May 29, 2014, at 10:45 AM, a tour of inpatient Radiology was conducted by a surveyor with the Assistant Director of Facilities.

a. In the patient bathroom the cabinet that the sink was set into was observe to be wooden and missing finish and a number of areas. Additionally, water was observed puddled around the sink on the wooden area around the sink.

b. The training stairway was observed to have an unfinished, porous surface. This was the most severe at the base.

c. These findings were confirmed with the Assistant Director of Facilities on May 29, 2014 at 11:00 AM.

Based on review of policies and procedures, review of information provided and tours of the facility and outpatient areas May 27-29, 2014, it was determined that the facility and outpatient areas failed to ensure that all the patient care equipment and non-clinical equipment was consistently maintained at an acceptable level of safety and quality.

Findings include:

1. A tour of the outpatient areas was conducted by a surveyor on May 27, 2014 with the Assistant Director of Facilities.

a. At 11:50 AM, a tour of the Pen Bay Specialty Clinic at 79 Schooner Street Damariscotta was performed and the following was observed: The following pieces of medical equipment were observed without stickers indicating that they had been inspected for safety of operation. In the first exam room - An exam table, an endoscopy light and an Otis-scope. In the second exam room, an exam table. Additionally the following was observed: an Intravenous Pole with rusty casters (an un-cleanable surface).

b. At 12:25 PM, a tour of Waldoboro Family Medicine at 27 Mill Street in Waldoboro was performed and an exam table was observed with a torn vinyl pad creating an un-cleanable surface.

c. At 12:55 PM, a tour of Pen Bay Physical Therapy (Rehabilitation Services) at 40 Washington Road in Waldoboro was performed. A radio and a refrigerator used for ice packs were observed without a sticker indicating they had ever been inspected for electrical safety.

d. At 2:00 PM, a tour of PBMC Outpatient Psychiatry at 15 Midcoast Drive, in Belfast was performed. Patient scales were observed in Rooms 11 and 14, that did not have stickers indicating that they had ever been calibrated or checked for safe operation.

e. At 2:55 PM, a tour of PBMC Rehabilitation Services at 116 Union Street (YMCA) in Rockport was performed. A radio and a treadmill were observed without a sticker indicating that they had been inspected for electrical safety. Additionally tears were observed on the vinyl covering the pads on an exam table and a low, wide treatment table.

f. At 3:10 PM, a tour of Dr. Kava's Practice at 68 Ben Paul Lane in Rockport was performed. A radio was observed without a sticker indicating it had been checked for electrical safety.

g. All of the above findings at these outpatient facilities were confirmed with the Assistant Director of Facilities on May 27, 2014 at 3:30 PM.

2. A tour of the outpatient areas was conducted by a surveyor on May 28, 2014, with the Clinical Care Manager and the Assistant Director of Facilities.

a. At 8:30 AM, a tour of PBMC Outpatient Psychiatry was performed and the following was observed: The patient scale in Room 15 did not show evidence of being calibrated (other scales had stickers indicating the date they had been inspected).

b. During an interview with the Assistant Director of Facilities on May 28, 2014 at approximately 8:30 AM, he stated that he would have the whole place checked so that all equipment would be inspected.

c. At 9:05 AM, a tour of Dr. Lawrence's Practice at 760 Commercial Street in Rockport was performed and the following was observed. A container of enzymatic cleaner was observed under the sink. In Exam Room 1 an exam table was observed with no electrical safety sticker. In exam room 2, dead insects were observed in a ceiling light fixture. In the patient rest room a container of "The Works, toilet bowel cleaner" and 2 empty plastic bottles were observed stored under the sink.

d. At 9:30 AM, a tour of Pen Bay Pediatrics at 7 Madelyn Lane in Rockport was performed. In the Lobster Room an exam table pad was observed with 2 tears in the vinyl creating an un-cleanable surface. In the Sea Horse Room a patient scale was observed without a sticker indicating it had been checked for calibration.

e. At 10:10 AM, a tour of Pen Bay Family Practice at 7 Madelyn Lane in Rockport was performed. In the staff break room a microwave, a toaster oven, a Mr. Coffee coffee maker, A Keurig coffee maker, and a refrigerator were observed without stickers indicating that they had been checked for electrical safety. In the laboratory area a Clinteck 50 urine analyzer was observed without a sticker indicating it had been inspected. In Room 233 an exam table was observed without a sticker indicating it had been inspected. In Room 204 a medical instrument table was observed with rusty casters creating an un-cleanable surface.

f. At 10:35 AM, a tour of the Center for Sleep Medicine at 7 Madelyn Lane in Rockport was performed. In the staff lounge, a table lamp, a microwave, a Hamilton Beach brew station, a toaster oven, a refrigerator, a floor lamp, and an Oster iced tea maker were observed without stickers indicating that they had been inspected for medical safety. In the Clean Utility Room an Intervenous pole was observed with rusty casters creating an un-cleanable surface. In each of the 5 patient rooms there was a television, 2 table lamps, and a fan. None of these 20 items were observed to have stickers indicating they had been inspected for electrical safety.

g. At 10:55 AM, a tour of Mid-Coast Speech/Hearing/Occupational Therapy at 7 Madelyn Lane in Rockport was performed. In the kitchen/staff break area a microwave, a refrigerator, and a hot pot/coffee maker were observed not to have stickers indicating they had been inspected for electrical safety.

h. At 11:45 AM, a tour of Pen Bay Rheumatology at 817 Commercial Street in Rockport was performed. A lamp and a radio were observed in the waiting room without stickers indicating that they had been inspected for electrical safety.

i. At 12:05 AM, a tour of Dr. Robert Merrill's Practice at 821 Commercial Street, Suite 1 in Rockport was performed. In Exam Room 4 an exam table tears in the vinyl covering of the exam table pad were observed.

j. At 1:35 PM, a tour of Pen Bay Urology and Nephrology at 3 Glen Cove Drive, Suite 3 in Rockport was performed. In the staff meeting room a refrigerator, microwave, and toaster oven were observed without a sticker indicating that they had been inspected for electrical safety. In Procedure Room 2 an Intravenous pole and a medical instrument table were observed with rusty casters. In the Procedure Utility Room a stool was observed with rusty casters. In Procedure Room 2 a medical instrument table was observed with rusty casters. In the Procedure Utility Room containers of the cleansers, Enzol, Clorox, Hinge Free, Speed Clean, and Premidex were observed under the sink.

k. At 1:35 PM, a tour of Pen Bay Women's Health at 3 Glen Cove Drive, Suite 1, in Rockport was performed. In the Clean Utility Room a cardboard box of sanitary pads was observed stored on the floor. In the urine testing area, a container of bleach was observed stored below the sink. In Procedure Room 16 a radio was observed without a sticker indicating it had been inspected for electrical safety.

l. At 2:40 PM, a tour of Pen Bay Surgery & Wound healing Center at 4 Glen Cove Drive, Suite 103, in Rockport was performed. An electric razor was observed without a sticker indicating it had been safety inspected.

m. At 2:55 PM, a tour of PBMC Rehabilitation services was begun at 4 Glen Cove Drive in Rockport. An exam table was observed in Room 2 that had tears in the vinyl covering the pad.

n. All of the above findings at these outpatient facilities were confirmed with the Clinical Care Manger and the Assistant Director of Facilities on May 28, 2014 at 3:00 PM. .

3. A tour of the Operating Room (OR) area was conducted by two (2) surveyors on May 28, 2014, with the Director of Surgical Services and the Assistant Director of Facilities at 3:30 PM.

a. Numerous Intravenous poles, tables, bucket holders, and carts with rusty casters were observed through-out the OR areas.

b. These findings were confirmed with the Director of Surgical Services and the Assistant Director of Facilities on May 28, 2014 at approximately 4:30 PM.

4. On May 29, 2014, a tour of outpatient areas conducted by a surveyor continued with the Assistant Director of Facilities.

a. At 9:25 AM, a tour of Pen Bay Rehabilitation Services at 4 Glen Cove Drive in Rockport was continued. A stool with a tear in the vinyl seat was observed in Treatment Room 6. In the Exercise Room a Biodex Chair was observed to have a tear in the vinyl seat.

b. These findings were confirmed with the Assistant Director of Facilities on May 29, 2014 at 9:50 AM.

5. On May 29, 2014, at 10:00 AM, a tour of inpatient Radiology was conducted by a surveyor with the Assistant Director of Facilities.

a. In an alcove a blanket warmer was observed with no sticker indicating it had been inspected for safety.

b. In the housekeeping closet a condensate pump was observed leaking into a bucket.

c. A moldy wooden stool was observed in X-Ray Room 2. This was removed immediately by the Assistant Director of Facilities. It was later observed in an equipment alcove.

d. These findings were confirmed with the Assistant Director of Facilities on May 29, 2014 at 10:40 AM.

6. During tours of the facility and outpatient areas on May 29, 2014, the following observations were identified:

a. The facility was not in compliance with the State of Maine, Internal Plumbing Code Regulations, Chapter 238 Section 11.1 C.3.e. "Direct connections between potable water piping and sewer connected wastes shall not exist under any condition with or without backflow protection. Where potable water is discharged to the drainage system, it shall be by means of an approved air gap. The size shall be two pipe diameters of the supply inlet, but in no case shall the gap be less than one inch." The drain pipes from the ice machine draining into a 3 inch drain pipe, without an air gap.

b. During the tour of the following units: Medical/Surgical (Med/Surg) North, Med/Surg South, PCAU, and PACA; the ice machines were checked for having an air gap. All four (4) of the ice machines drained into the drain pipe and there was no gap between the ice machine drain and the discharge drain.

7. The above findings were confirmed by the Director of Nursing and the Unit Managers of each unit at the time of the observations on May 29, 2014, between 9:45 AM and 11:45 AM.

8. During an interview with the Director Facility and Support Services on May 29, 2014, at approximately 3 p.m., he stated that there was only a draft policy related to checks of non-clinical electrical equipment. He stated that he will be developing a policy that relates to both non-clinical and clinical equipment and has time frames included regarding checks of such equipment.

9. On May 28, 2014, from 8:30 AM until 4:30 PM, and on May 29, 2014, from 8 AM until 2 PM, tours of the facility were conducted. The tours revealed the following:

a. a. Obstetrical Unit - The nursing station contained a freezer with no sticker identifying it had a safety check before going into service; additionally, the freezer was caked with ice and therefore not working at capacity; the blanket warmer had no sticker verifying a safety check and there were no temperatures being recorded; the microwave used for rice packs had no sticker verifying that it had a safety check prior to use in the unit; the patient care room nearest the Nursing Station contained a fetal monitor and a large box fan with no stickers verifying that they had been checked for safety prior to use; the nursery break room contained a microwave, a refrigerator and a Keurig coffeemaker that had no stickers verifying a safety check before use; a small storage area contained a "Mighty Vac" that was last checked on November 2011 (this was removed from the area); Room 1112 contained a small table fan with no safety sticker (this was removed from service); the Family Room contained a microwave, coffee maker, toaster and refrigerator with no sticker indicating a safety check had been performed; Room 1124 had a small yellow lamp with no safety check sticker; and the Reception Area had a small table fan with no safety check sticker.

b. PREP Area - in the reception area there was a microwave, a toaster and a refrigerator with no safety check sticker.

c. Infusion Clinic - the blanket warmer had a safety sticker dated February 2013 and there was no log being kept of the temperatures; there was a small white fan at the nurses station that had no safety sticker and the small nutrition center had a toaster and a large refrigerator with no safety stickers.

10. These findings were confirmed by the Chief Operating Officer and the Director Facility and Support Services on May 28, 2014, while on tour with the surveyor.

11. During a tour of the Emergency Department on May 27-29, 2014, the following equipment items were found to be expired:

a. ED Room 2: One (1) Rusch Quick-Trach Cricothyrotomy Kit, expired "4/14"; one (1) 5.0 mm endotracheal tube, expired "1-2013"; and one (1) Pediatric Chest Tube Tray, expired "2-2012".

b. Medication (Pyxis) Room: Thirteen (13) 1 ml syringes, expired "2013-02".

c. These findings were confirmed by the Nurse Manager, Emergency Department, on May 28, 2014, at approximately 10:00 AM.






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