HospitalInspections.org

Based on observations and interviews with key personnel on April 19-21, 2016, it was determined that the facility failed to provide preventive maintenance programs to insure all essential mechanical, electrical, and patient care equipment were maintained in a safe operating condition.

The finding includes:

The pull cord for the nurse call light was observed to be wrapped around the grab bar, disabling the function of the call light on April 19, 2016 at 11:35 AM in the Emergency Department Public/Patient Restroom. This was confirmed and corrected at the time of the observation by an Emergency Department Technician.

The pull cord for the nurse call light was observed to be wrapped around the grab bar, disabling the function of the call light on April 20, 2016 at approximately 8:30 AM in the Ambulatory Surgery Unit Public/Patient Restroom. This finding was confirmed by the Systems Maintenance and Construction Manager.

During a tour of the Medical/Surgical Unit on April 20, 2016, at approximately 9:00 AM, an infant scale was observed with no sticker indicating it had been inspected/calibrated for patient safety. This was confirmed at the time with the Systems Maintenance and Construction Manager.

Based on observations and interviews with key personnel on April 19-21, 2016, it was determined that the facility failed to keep the premises clean and orderly.

The finding includes:

On April 19, 2016 at 1:15 PM, floor tiles were discovered with an approximately 1/8th inch, unsealed gap between floor tiles, creating uncleanable surfaces, in Room 101 of Naples Family Practice.

On April 19, 2016 at 1:45 PM, floor tiles were discovered with an approximately 1/8th inch, unsealed gap between floor tiles, creating uncleanable surfaces, in the waiting room restroom of North Bridgton Family Practice.

On April 19, 2016 at 2:00 PM, non-intact vinyl was discovered on a positioning device, creating an uncleanable surface, in Operating Room 2.

On April 19, 2016 at 2:25 PM, a non-intact vinyl cover was observed, creating an uncleanable surface, on an arm of the phlebotomy draw chair at Fryeburg Family Medicine.

On April 20, 2016 on a tour of the hospital campus which began at approximately 8:15 AM and ended at approximately 3:30 PM, non-intact vinyl was observed on an exam chair in Room 8 of Internal Medicine and a positioning cushion in Nuclear Medicine, creating uncleanable surfaces.

On April 20, 2016 on a tour of the hospital campus which began at approximately 8:15 AM and ended at approximately 3:30 PM, the following was observed which created uncleanable surfaces: A suction device stand/pole (rusty casters) in the Equipment Room of the Medical/Surgical Unit; on an Intravenous (IV) pole (rusty base) in the Computerized Tomography (CT) Room; and on two IV Poles (bases with missing paint) in the Oncology Infusion Room.

On April 21, 2016 at approximately 8:00 AM, the following was observed in Operating Room 1 which created uncleanable surfaces: A biohazard pail on wheels (rusty casters); an IV pole with a Bair Hugger device attached (rusty casters) and on an IV pole with a tourniquet device attached (paint missing from base).

On April 19, 2016 at approximately 1:45 PM, the interior surface of the bins holding patient supplies in the store room of North Bridgton Family Practice were observed to have a layer of dust.

On April 19, 2016 at approximately 2:30 PM, three stained ceiling tiles were observed, indicating water leakage and creating a potential habitat for mold growth, in Exam Room 4 at Fryeburg Family Medicine.

On April 20, 2016 on a tour of the hospital campus which began at approximately 8:15 AM and ended at approximately 3:30 PM, a stained ceiling tile was observed, indicating water leakage and creating a potential habitat for mold growth in Room 103 of the Medical/Surgical Unit.

On April 20, 2016 on a tour of the hospital campus which began at approximately 8:15 AM and ended at approximately 3:30 PM, dust on high horizontal surfaces were observed: In Room 101 (lift rails) and Room 130 (paper towel dispenser) on the Medical/ Surgical Unit; in Bay 128 (top surface of the white board and in the bathroom on the top surface of the light cover and paper towel dispenser) on the Ambulatory Surgical Unit; and in Exam Room 6 (on top of the cabinet) and Exam Room 1 (on the arm of the light over the bed and on top of the cabinet) in the Emergency Department.

All of the above findings were confirmed by the Systems Maintenance and Construction Manager at the date and time that they were discovered.

Based on observation and interviews with key personnel on April 21, 2016 at approximately 10:00 AM, it was determined that the facility failed to assure that pharmaceuticals were stored in accordance with manufacture's recommendations and acceptable standards.

The finding includes:

During a tour of the North Bridgton Family Practice, in the "sample medication", (medications provided to patients at the clinic), storage area, it was noted that insulin samples were stored in a mini-refrigerator that failed to have temperature monitoring. No thermometer (electronic or mechanical) was noted when observing the contents of the refrigerator.

The Practice Manager was asked if the temperature monitoring logs were available for this refrigerator, she replied that she did not know where it was located and checked with other staff present. The Practice Manager returned stating that none of the staff present were able to provide the location of the temperature monitoring logs.

The FDA (Federal Food and Drug Administration) states the following: "According to the product labels from all three U.S. insulin manufacturers, it is recommended that insulin be stored in a refrigerator at approximately 36°F to 46°F. Unopened and stored in this manner, these products maintain potency until the expiration date on the package."

On April 21, 2016 at approximately 10:15 AM, the Practice Manager stated, "I have to assume that there are no temperature logs and that we are not monitoring the temperatures of this refrigerator" (confirming that the insulin storage refrigerator was not monitored and the facility could not assure that the contents were maintained at the proper temperature range).

The hospital's Pharmacist was advised of this finding on April 21, 2016 at approximately 11:10 AM, and confirmed that the refrigerator temperatures needed to be monitored and logged, and that the current contents needed to be removed and discarded, as the viability and safety of the product could no longer be assured.