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Based on observations and interviews with key personnel on March 12-13, 2013, it was determined that the critical access hospital failed to ensure that the physical plant, equipment and supplies were maintained to ensure the safety of staff and patients.

Findings include:

1. During a tour of the endoscopy procedure room on March 13, 2013 at approximately 12:30 PM, surveyors noted:
a. Cough drops and candy in a cabinet and on a shelf;
b. One (1) of six (6) cytology brushes were expired;
c. A small metal table had rusty castors; and
d. A ceiling vent had dust and white powder inside it.
These findings were confirmed with the Manager of surgical services at the time of the tour.

2. During a tour of the ambulatory surgery and PACU rooms on March 13, 2013 at approximately 12:30 PM, surveyors noted stained ceiling tiles in the Admission/Discharge Room. These findings were confirmed with the Manager of surgical services at the time of the tour.

3. During a tour of the surgical suite on March 13, 2013 at approximately 1:00 PM, surveyors noted:
a. Rusty castors on a table, a suction stand, and the cautery unit cart in Operating Room 1;
b. Stained ceiling tiles in the substerile area;
c. Rusty castors on the cautery unit cart, a ring stand, and a laundry basket cart in Operating Room 2;
d. A tear, which had been patched with a clear bandage, in the operating table cover in Operating Room 2;
e. Three (3) 10 cc 20 gauge syringes with stained packaging in the malignant hyperthermia cart;
f. Six (6) expired Foley catheters (with expiration dates between February 2006 and August 2008) stored in a plastic bag under the malignant hyperthermia cart;
g. One (1) catheter insertion tray which had expired March 1985 in the plastic bag under the malignant hyperthermia cart;
h. Multiple ceiling tiles with stains, cracks, and/or holes in central sterile supply above the clean carts;
i. Large pads in cardboard boxes on the floor in central sterile supply;
j. Chipped paint on a white cart in the receiving area of central sterile supply; and
k. Stained and cracked ceiling tiles in the anesthesia closet.
These findings were confirmed with the Manager of surgical services at the time of the tour. The expired Foley catheters and catheter insertion tray were discarded by the Manager at the time of the tour.

4. On March 12, 2013 during the inspection of the kitchen the surveyor observed that the rubber floor mats were torn. This citation was discussed with the kitchen manager.

5. During the tour of the hospital on March 12, 2013, the following items were observed.
a. Ceiling tiles were stained in the Computer Server Room.
b. The paint on the floor was peeling,and an extension cord was being used to supply power to a desk in Central Supply.
c. The flooring was worn at the nurses' station in the Emergency Room.
d. The floor tiles were cracked in the bathroom in Rehab Services.
e. Paint was peeling from several steam radiators in offices on the second floor in the "old" building.

6. During the tour of the Bucksport Health Clinic on March 12, 2013, the surveyor observed that the laminate counter was chipped in exam room #3.

7. During inspection of the Sussman Building, the surveyor observed that five (5) expired vacutainers were in the laboratory.

8. Citation numbers 4,5,6 and 7 were discussed with the Facilities Manager at the date and time they were observed.




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Based on observations and interviews with key personnel on March 13, 2013, it was determined that the governing body failed to ensure that surgical procedures were performed in a safe manner with appropriate emergency equipment available. For further information see Tags C-076, C-0222, C-0271 and C-0320.

Based on observations and interviews with key personnel on March 13, 2013, it was determined that the critical access hospital failed to ensure that staff complied with patient care policies.

Findings include:

The 'Toy Safety' policy stated that toys are "allowed in the Rehab Department for therapy only". During a tour of the ambulatory surgery and PACU rooms on March 13, 2013 at approximately 12:30 PM, surveyors noted multiple stuffed animals in the hall and beside the linen cart. These findings were confirmed with the Manager of surgical services at the time of the tour, who stated that these toys were sometimes utilized with pediatric patients.

Based on observations and interviews with key personnel on March 13, 2013, it was determined that the critical access hospital failed to ensure that expired medications were removed from the malignant hyperthermia cart in the surgical suite.

Findings include:

During a tour of the surgical suite on March 13, 2013, at approximately 1:30 PM, surveyors noted that the malignant hyperthermia cart had a checklist taped its front dated August 2012 which included expiration dates of the medications. The list included Mannitol, which had expired 12/1/12. The cart contained two (2) bottles of Mannitol which had expired 12/1/12, a container of Calcium Chloride 100 mg/ml (milligrams per milliliter) injection which had expired April 2012, and two (2) 1,000 cc (cubic centimeters) bags of sterile water which had expired 1/1/10. These findings were confirmed with the Manager of surgical services at the time of the tour. The Manager stated that she was not sure if anesthesia or the pharmacy was responsible for checking these medications.

Based on observations and interviews with key personnel on March 13, 2013, it was determined that the critical access hospital failed to ensure that surgical procedures were performed in a safe manner with appropriate emergency equipment available.

Findings include:

1. During a tour of the endoscopy suite on March 13, 2013 at approximately 12:30 PM, surveyors noted that there was no endoscope sterilization log. During an interview with the Manager of surgical services and the Chief Nursing Officer on March 14, 2013, at approximately 10:30 AM, the Manager stated,"about 40 or 50 scopes were used during that time [January and February 2013] with no evidence that the scopes were cleaned." Although surveyors confirmed through interview, observation and review of the print outs from the sterilization that the endoscopes were being sterilized per the 'Cleaning Video Scope' policy, the 'Record of Sterilization,' received on March 14, 2013, contained no documentation of the cleaning and sterilization of the video endoscopes from December 5, 2012 until March 11, 2013.

2. During a tour of the surgical suite on March 13, 2013, at approximately 1:30 PM, surveyors noted that the malignant hyperthermia cart had a checklist taped its front dated August 2012 which included expiration dates of the medications. The list included Mannitol, which had expired 12/1/12. The cart contained two (2) bottles of Mannitol which had expired 12/1/12, a container of Calcium Chloride 100 mg/ml (milligrams per milliliter) injection which had expired April 2012, and two (2) 1,000 cc (cubic centimeters) bags of sterile water which had expired 1/1/10. These findings were confirmed with the Manager of surgical services at the time of the tour. The Manager stated that she was not sure if anesthesia or the pharmacy was responsible for checking these medications.

3. During a tour of the surgical suite on March 13, 2013, at approximately 1:30 PM, surveyors noted that the code cart in the hallway had no defibrillator and that the daily checks were not being completed. The Manager stated that the defibrillator had failed and that the OR was utilizing the code cart from SCU until it could be replaced. During interviews with two (2) RN's in the surgical suite at approximately 1:45 PM, one stated that she would get the code cart from SCU if needed, while the other stated that she would get the cart from the hallway. These findings were confirmed with the Manager of surgical services at the time of the tour and interviews.

4. During a tour of the surgical suite on March 13, 2013, at approximately 1:30 PM, surveyors noted that the intubation cart contained multiple expired endotracheal tubes. The thirteen (13) endotracheal tubes contained in the cart all had expiration dates between December 2003 and April 2009. Additionally, two (2) of the packages were open. During an interview with the CRNA, she stated: "This is wrong, and I will fix it." The CRNA also stated that there was currently no system in place to check the cart for expired equipment. These findings were confirmed with the Manager of surgical services at the time of the tour and interview.

5. The potential outcome of having no defibrillator, having expired medications and supplies on three (3) of three (3) emergency carts was that surgical staff would fail to have the equipment, supplies and medications necessary to properly care for patients in an emergency situation.

6. For additional information on the failure to provide surgical services in a safe manner related to pharmaceutical services, physical plant and environment, and patient care policies see Tags C-076, C-222 and C-271.


The cumulative effective of these deficient practices resulted in this Condition of Participation being out of compliance.