HospitalInspections.org

Based on review of personnel files and interviews with the Human Resources Director on October 22, 2014, it was determined that there was no documented evidence that a criminal background check had been done on all applicable personnel in one (1) of thirteen (13) personal files (PERSONNEL FILE A).

Findings include:

1. The Maine Revised Statutes Annotated, Title 22, Subtitle 2, Part 4, Chapter 401, subsection 1724 states; "Beginning October 1, 2010, a facility or health care provider subject to the licensing or certification processes of chapter 405... shall obtain, prior to hiring an individual who will work in direct contact with a consumer, criminal history record information on that individual, including, at a minimum, criminal history record information from the Department of Public Safety, State Bureau of Identification."

2. Thirteen (13) applicable personnel files were reviewed on October 2, 2014. Personnel file A did not contain documentation that a criminal background check had been conducted. The staff person had a hire date of November 19, 2010.

3. The above finding was confirmed by the Human Resources Director on October 22, 2014, at approximately 1:05 PM.

Based on the review of patient medical records and interview with staff on October 22, 2014 at approximately 3 PM, it was determined that the facility failed to inform patients of their rights in advance of furnishing care.

Findings include:

1. Three (3) of thirty (30) patient records reviewed (records FFF, HHH, and III), did not contain documentation that the facility informed patients of their rights in advance of furnishing care.

2. These findings were confirmed by the Quality Manager on October 22, 2014 at approximately 3 PM.

Based on review of patient records and interview with staff on October 22, 2014 at approximately 3 PM, it was determined that the facility failed to provide patients with the right to formulate an advanced directive.

Findings include:

1. Two (2) of thirty (30) patient records reviewed (patient records FFF and III), did not contain documentation that the patients were provided the right to formulate an advanced directive.

2. These findings were confirmed by the Quality Manager on October 22, 2014 at approximately 3 PM.

Based on document review and interview with staff on October 22, 2014, it was determined that the facility failed to obtain a physician's order prior to restraining a patient.

Findings include:

1. The medical record of patient "U" indicates in the physician progress note "During the Emergency Department (ED visit on May 21, 2014, the patient attempted to leave the ED and "...pushed the security guard into the door... At the time 2 other ED staff tried to help get the patient off of the security guard and everyone ended up on the floor trying to hold the patient down and restrain him... Due to the fact that the patient was now being restrained on the floor, with 5 staff members..."

2. The ED medical record of patient "U" for service date May 21, 2014, did not contain a physician order for the restraint episode that was documented in the ED medical record.

3. This was confirmed by the Chief Nursing Officer on October 22, 2014 at approximately 12:30 PM.

Based on review of medical records and interviews with the Director of Pharmacy on October 22, 2014, at 9:45 AM, it was determined that there was no documented evidence that the physician was immediately notified of a drug administration error in one (1) of five (5) medical records (RECORD: A).

Findings include:

1. Five (5) medical records were reviewed on October 22, 2014, at approximately 8:30 AM, Record A did not contain any documentation that the a physician had been notified immediately of a drug administration error.

2. An interview with the Director of Pharmacy on October 22, 2014, at approximately 9:45 AM, revealed that the pharmacist who was aware of the error did not notify the physician.

3. During a telephone interview with the Clinical Quality Specialist on October 22, 2014, at approximately 9:50 AM, it was confirmed that Record A did not contain any documentation that a physician had been notified of the drug administration error.

Based on tours conducted with the Manager of Plant Operation on October 21 & 22, 2014, it was determined that the facility failed to maintain the physical plant and overall hospital environment so that the safety and well-being of patients are assured.

Findings include:

1. The doors leading to the outside of the hospital on the F wing, ASU and Plant Operation were found to have rusted door frames especially around the base of the doorways.

2. The Operating Rooms had several stools, rolling equipment, and trash bins with rolling casters that were rusted, and not easily sanitized.

3. The portable computers on the Medical Surgical Unit had torn and taped wrist rests, and not easily sanitized.

4. The flooring surrounding the Nursing Stations on the Medical-Surgical Unit, Emergency Department and the Emergency Registration areas, were stained, worn, and not easily sanitized.

5. Two walls in the Dietary Department were scared, gauged with worn paint, and not easily sanitized.

6. There were damaged or discolored ceiling tiles on the F Wing section of the hospital and Dietary Department.

7. Storage bins used for patient supplies throughout the hospital were found to be soiled.

8. Floor corners in several areas of the the hospital were encrusted with dirt.

9. The boiler room floor had debris in several areas.

10. The above findings were confirmed with the Manager of the Plant Operation on both October 21 & 22, 2014 as the tour was being conducted.