HospitalInspections.org

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

The following provisions of subsistence needs for staff and patients were not included in the Emergency Preparedness Plan provided during the survey:

1) Food
2) Water
3) Fuel

This standard is not met as evidenced by:
During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

The Emergency Preparedness Plan did not include the specific transportation required for safe evacuation from the facility.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

The Emergency Preparedness Plan did not include the development of arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

The Emergency Preparedness Plan did not include the training program required for the initial training and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

The Emergency Preparedness Plan did not include the full-scale exercise or additional approved exercise required.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Facilities and surveyor 05910, surveyor 37694 did observe:

A fuel contract to provide the generator with the means to operate in the event of an emergency was not included in the Emergency Preparedness Plan.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Non-conforming structure attached to the hospital. A wooden platform Type V(000) was added to the existing hospital structure (Type II (111) where the Temporary Nuclear Moblie unit is located.


35163

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The chiller room, boiler room, and generator room had missing fire proofing in several areas, on the structural beams.

2. Tel-Data room #1110 had areas missing fire proofing on the structural beams.

3. The electrical room located behind the operating room nursing station had areas of missing fire proofing on the structural beams.

Based on observation of surveyor 16732 and 35163 on July 23, 2018:


Emergency Room department have several soiled linen carts stored in their corridors

The maintenance worker was present during this observation.



34673

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Sign in PACU corridor hanging at 6'-6" . 6'-8" minimum headroom clearance.

Items being stored (Computers on wheels, ladder and imaging equipment) in corridor near exit and entrance to temporary Nuclear Medicine unit.

Double doors located on Level 1 at the entrance of the Nuclear Medicine Imaging corridor and the waiting area Obstruct egress. These doors swing against egress, Exit signs located in this area direct people through these double doors and with the current exiting configuration these doors obstruct egress.

Stairwell WS1-0 Exit sign required at level # 2 and a sign preventing people from accessing a gate at this level shall be posted "NOT an EXIT".


Door A/B2 shall swing towards egress.

Storage located in the elevator lobby beyond Door A/B2 shall be removed.

Dirty Laundry hampers, a table and other machinery stored in corridor near recovery D218A

Soiled linen and soiled linen hampers stored in cross corridor in the ICU.


35163

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The fold down charting tables located in C-3 corridor did not self close and could become an obstruction to egress. It appears the closing devices no longer have the power to retract the tables to the closed position.

2. The corridors located throughout the area serving the operating rooms has storage within the corridors that was not directly related to patient transport or emergency care (operating supplies, carts etc.). These items could cause an obstruction to egress.

3. Storage cabinets were being stored in corridor near room # F1131 and could cause an obstruction to egress.


37694

This standard is not met as evidenced by:

While inspecting this facility on July 23, 2018 with the Maintenance Technician and surveyor 39983, surveyor 00452 did observe:

Gurney stored in Stair Lobby B-2.

Gurney stored in Stairwell #4 on Level 3 in Elevator Lobby.

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. two sets of exit/entrance bi-fold doors located near the emergency department registration desk did not have the required signs that instructed occupants to push to open during an emergency.

2. Exit door located near loading dock required excessive force to open. When tested with a pressure gauge it revealed that in excesses of 30 pounds of pressure was required to open the door. It appears the door is binding on the bottom threshold.

3. The bi-fold exit doors located at the ambulance entrance/exit in the emergency department have, has had the motion sensor (that automatically opens the door when someone is within the proximity of the doors) disabled by facility maintenance staff. It now requires occupants to push the the handicap button to operate the doors to exit the space and there is no sign to direct occupant and could cause an obstruction to egress.

Based on observation of surveyors 16732 and 35163 on July 23, 2018

Stairway 3 near mechanical room (F1 and S2) has sprinkler pipe that has penetrated a two hour fire rated stair tower wall with no fire stopping present.

The maintaince worker was present during this observation

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

One hour fire rated double doors located at the main corridor of the Pre-admission testing suite on level 1 did not latch at the bottom of the door.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Ground level stairwell door WS1-0. Door (90 minute fire rated) and door jamb had multiple holes.


37694

This standard is not met as evidenced by:
While inspecting this facility on July 23, 2018 with the Maintenance Technician and surveyor 39983, surveyor 00452 did observe:

Ceiling penetration at the top of the Stair Tower 401.

Based on observation of surveyor 16732 on July 23,2018

Storage and mechanical room door located behind valet stand, was being propped open with a electrical box fan. The door is required to be closed at all times.

C-3 Linen door does not self closer and positive latch

B-305 Storage room does not have a self closer


The maintenance worker was present during this observation


34673

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

The clean room storage area had four small penetrations in the wall.

Electrical room located in the Pre-admission testing suite on level 1 ; unprotected penetrations through the floor.



35163

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The boiler room has polyurethane spray foam sealing gaps around pipes located on the wall left of the stairs. There was no fire stopping material present and would not prevent the passage of fire.

2. Tel-Data room #1110 did not have a self closing device and is over 50 sq/ft and with combustible storage.

3. Storage room A331B (over 50sq/ft) has a fan in the wall shared with the adjacent conference room and would not prevent the passage smoke into the conference room.

4. Room A350-Laundry room has a crushed flexible hose being used to vent the dryer and was allowing lint to build up behind the dryer.

5. The housekeeping storage room located in the operating room area (over 50 sq/ft-combustible storage) did not have a self closing device on the door.



37694

This standard is not met as evidenced by:While inspecting this facility on July 23, 2018 with the Maintenance Technician and surveyor 39983, surveyor 00452 did observe:

Electrical Room C-478 has electrical conduit penetration through to adjoining room.

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. Tel-Data room # 1110 had polyurethane spray foam and no documentation was provided to indicate it meets interior finish requirements.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Escutcheon plate missing from sprinkler head in Imaging room across from nurses station on the first floor.

Escutcheon plate missing from sprinkler head in employee lounge first floor.

Double doors entering Nuclear Medicine from waiting area; sprinkler head obstruct by the door closing device.



35163

Based on observations and records review surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The sprinkler standpipe/hose cabinets were tagged out of service, hose removed and piping capped, by the facility and no documentation could be provided to indicate that the removal of these devices was approved. There was also no documentation to indicate that they have been tested within the last 12 months.

2. Angio-storage room had items stored within 18" of the sprinkler head and would not allow for proper sprinkler pattern development.

Based on observation of surveyor 16732 on July 23, 2018

Patient room door number 336 does not latch when closed

Patient room door number A 337 has a wash cloth placed under the door to keep it from closing

The maintenance worker was present during this observation



34673

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Room # 3 in the ICU cross corridor shall latch and resist the passage of smoke.

Reception area near ICU; sliding glass window located in the corridor shall latch.


35163

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. Operating room door# 6 would not properly latch. The latching mechanism was stuck in the retracted position, would not release upon door closure and therefore would not prevent the passage of smoke.

Based on observation of surveyor 16732 on July 23, 2018


C-3 Electrical room has penetrations in the walls and ceilings that will not resist the passage of smoke

The maintenance worker was present during this observation







37694

This standard is not met as evidenced by:While inspecting this facility on July 23, 2018 with the Maintenance Technician and surveyor 39983, surveyor 00452 did observe:

Wall penetration found above the corridor smoke barrier doors by C-473.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:


Smoke barrier doors located near room C-118 would not completely close because doors were rubbing together.

Level 2 smoke barrier doors near elevators and located between smoke compartment 2.w1 and 2.w2 do not completely close.

Smoke Barrier doors near W203 do not completely close.

Smoke barrier doors near ICU and reception desk shall close and resist the passage of smoke.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Plant Operations and surveyor 05910, surveyor 37694 did observe:

The 3rd shift fire drill report on 10/11/17 indicated that it was a verbal drill. Documentation was inconclusive as to whether a coded announcement was made.

Multiple fire drill reports indicated that the coded announcements were not heard clearly from within the Women's Health Center, C-2 or in Security.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Nuclear Medicine room C118 Renovations. Unprotected wall penetrations and sprinkler heads not found in the correct position.

This renovation also requires State of Maine Fire Marshal permit.

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The zone valves for the piped in medical gas, located near room #21 were obstructed by items stored in front of the cabinet.

2. The zone valves for the piped in medical gas, located near triage room # F1131 were obstructed by items stored in front of the cabinet.

This standard is not met as evidenced by:
During record review of this facility on July 23, 2018 with the Director of Plant Operations and surveyor 05910, surveyor 37694 did observe:

The following deficiencies were noted from the July 12-13, 2017 inspection report from William G. Frank and have yet to be remedied or scheduled to be remedied:

Maintenance Discrepancies found in the report are as follows:

Radiology
X-Ray 5: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 9 psig at 3.5 scfm
X-Ray 6: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 8 psig at 3.5 scfm
X-Ray 2: 3rd Vacuum inlet has a low flow of 1.75 scfm & 1st oxygen outlet drops 11 psig at 3.5 scfm.
Outpatient
Minor 1: 1st vacuum inlet has a low flow of 2.0 scfm & 3rd vacuum inlet has a low flow of 2.0 scfm
Minor 2: 1st vacuum inlet has a low flow of 1.0 scfm

Telemetry
Room 231: Vacuum inlet has a low flow of 1.75 scfm & Oxygen outlet drops 50 psig at 1.5 scfm
Room 233: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 8 psig at 3.5 scfm
Room 235: Vacuum inlet has a low flow of 2.0 scfm
Room 237: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 10 psig at 3.5 scfm
Room 239: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 50 psig at 2.0 scfm
Room 241: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 10 psig at 3.5 scfm
Room 250: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 10 psig at 3.5 scfm
Room 251: Vacuum inlet has a low flow of 1.5 scfm & Oxygen outlet drops 50 psig at 0.5 scfm
Room 252: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 50 psig at 2.0 scfm
Room 253: 1st vacuum inlet has a low flow of 2.0 scfm, 1st oxygen outlet drops 50 psig at 2.75 scfm & 2nd vacuum inlet has a low flow of 2.0 scfm
Room 254: Vacuum inlet has a low flow of 2.0 scfm
Room 255: Vacuum inlet has a low flow of 2.0 scfm
Room 256: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 10 psig at 3.5 scfm
Room 257: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 10 psig at 3.5 scfm
Room 258: Vacuum inlet has a low flow of 1.5 scfm & Oxygen outlet drops 50 psig at 1.5 scfm
Room 259: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlets drops 7 psig at 3.5 scfm
Room 260: 1st vacuum inlet has a low flow of 2.0 scfm, 1st oxygen outlet drops 6 psig at 3.5 scfm, 2nd vacuum inlet has a low flow of 2.0 scfm & 2nd oxygen outlet drops 7 psig at 3.5 scfm
Room 263: Vacuum inlet has a low flow of 2.0 scfm

Chemical Dependency
Room 404: Vacuum inlet has a low flow of 2.5 scfm & Oxygen outlet drops 50 psig at 3.0 scfm
Room 406: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 44 psig at 3.0 scfm
Room 408: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 44 psig at 3.5 scfm
Room 423: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 33 psig at 3.5 scfm
Room 424: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 35 psig at 3.5 scfm
Room 425: Vacuum inlet has a low flow of 2.5 scfm & Oxygen outlet drops 34 psig at 3.5 scfm
Room 426: Vacuum inlet has a low flow of 2.5 scfm & Oxygen outlet drops 38 psig at 3.5 scfm
Room 427: Vacuum inlet has a low flow of 2.25 scfm & Oxygen outlet drops 7 psig at 3.5 scfm
Room 429: Vacuum inlet has a low flow of 2.0 scfm & Oxygen outlet drops 7 psig at 3.5 scfm

Cancer Center
Room 451: Vacuum inlet has a low flow of 1.75 scfm
Room 459: 1st oxygen drops 33 psig at 3.5 scfm
Room 461: Oxygen outlet drops 8 psig at 3.5 scfm
Room 463: Vacuum inlet has no registered flow & Oxygen outlet drops 7 psig at 3.5 scfm
Room 464: 1st vacuum inlet has a low flow of 1.75 scfm, 1st oxygen outlet drops 40 psig at 3.5 scfm, 2nd vacuum inlet has no flow & 2nd oxygen outlet drops 8 psig at 3.5 scfm
Room 465: 1st oxygen outlet drops 8 psig at 3.5 scfm & 2nd oxygen outlet drops 8 psig at 3.5 scfm
Room 466: 1st vacuum inlet has a low flow of 1.5 scfm, 1st oxygen outlet drops 13 psig at 3.5 scfm, 2nd vacuum inlet has a low flow of 1.5 scfm & 2nd oxygen outlet drops 11 psig at 3.5 scfm
Room 468: 1st vacuum inlet has a low flow of 2.0 scfm, 1st oxygen outlet drops 17 psig at 3.5 scfm, 2nd vacuum inlet has a low flow of 2.0 scfm & 2nd oxygen outlet drops 23 psig at 3.5 scfm
Room 470: Vacuum inlet has a low flow of 1.75 scfm & Oxygen outlet drops 17 psig at 3.5 scfm
Room 476: 1st vacuum inlet has a low flow 2.75 scfm & 1st oxygen outlet drops 50 psig at 1.5 scfm

Compliance Discrepancies found in the report are as follows:

Radiology
Zone valves located right of X-Ray 2 have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)

Outpatient
Zone valves located left of Recovery have no pressure/vacuum indicators on the station outlet/inlet side of the zone valves. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)
Zone valves located left of Recovery have compression fittings on each side of the oxygen valve. (NFPA 99, 2012 edition paragraph 5.1.10.10(1))

Telemetry
The vacuum inlets in Telemetry are not supplied through a zone valve. (NFPA 99, 2012 edition paragraph 5.1.4.8)
Oxygen zone valve located left of room C234 Soiled Utility has no pressure indicator on the station outlet side of the zone valve. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)
Oxygen zone valve located left of room C234 Soiled Utility has compression fittings on each side of the valve. ( NFPA 99, 2012 edition paragraph 5.1.10.10(1))

Cancer Center
There are no vacuum zone valves for this department. (NFPA 99, 2012 edition paragraph 5.1.4.8)
Oxygen zone valve left of room 452 has no pressure indicator on the station outlet side of the zone valve. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)
Oxygen zone valve left of room 461 has no pressure indicator on the station outlet side of the zone valve. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)
Oxygen zone valve left of room 461 is a non-compliant valve. (NFPA 99, 2012 edition paragraph 5.1.4.3)
Oxygen zone valve across from room 463 has no pressure indicator on the station outlet side of the zone valve. (NFPA 99, 2012 edition paragraph 5.1.4.8.3)
Oxygen zone valve across from room 463 is a non-compliant valve. (NFPA 99, 2012 edition paragraph 5.1.4.3)
Oxygen zone valve across from room 463 is installed behind a normally open or normally closed door. (NFPA 99, 2012 edition paragraph 5.1.4.8.5)

Master Alarms and Sources

Nitrogen Manifold
Source valve needs to be relabeled with the name for the specific medical gas, rooms or areas served, and caution to not close or open the valve except in emergency. (NFPA 99, 2012 edition paragraph 5.1.11.2.1 and 5.1.11.2.3)
Source valve is not located in a secured area, locked in an open position. (NFPA 99, 2012 edition paragraph 5.1.4.7.3)
There is no riser valve on the piping feeding the Angio Room in the Radiology Department. (NFPA 99, 2012 edition paragraph 5.1.4.6)

Medical Air Compressor
All turns, offsets, and other changes in directions to the intake piping are not brazed. (NFPA 99, 2012 edition paragraph 5.1.10.3.1 and 5.1.10.4

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. The remote enunciator panel for generator #1 failed to emit audio tone when test button was depressed. The remote enunciator panel for generator #2 tested appropriately.

On 7-23-2018 while surveying the facility with Director of facilities and surveyor 40403 it was observed:

Multi- power strip located on the floor in the nurses station in the PACU area.

Level 1 Ultra Sound area; Multi power strip located on the floor.


35163

Based on observations surveyors 35163, and 16732 on 07/23/18, in the presence of maintenance the following was not met;

1. B.E.D. nursing station had a multi outlet power strip being used as a permanent source of power for the toaster, microwave and kureig coffee maker.

2. Mammography nursing station had a multi outlet power strip being used as a permanent source of power for a microwave and mini refrigerator.

3. The multi outlet power strip located behind the operating room nursing station was hanging from the power cord and causing excessive stress the device and electrical receptacle.

This standard is not met as evidenced by:

During record review of this facility on July 23, 2018 with the Director of Plant Operations and surveyor 05910, surveyor 37694 did observe:

The emergency plan and policies for the Hyperbaric Chamber are written in accordance with NFPA 99, The Standards for Healthcare 1999 Edition. The emergency plans and policies need to be written in accordance with the NFPA 99, The Standards for Healthcare 2012 Edition. This was a repeat violation from the 1/16/18 survey.