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Based on document reviews, interviews, and observations, it was determined that the Standard for Nursing Services, also known as C-1046, was not met as evidenced by the facility's failure to Ensure Nursing staff were scanning patient identification bracelets ("wristbands") on patients' wrists prior to medication administration on one (1) out of one (1) observed inpatient care unit (The Acute Care Unit).

Please see Tag C-1049 for details.

Based on document reviews, interviews, and observations, the facility failed to ensure Nursing staff were scanning patient identification bracelets ("wristbands") on patients' wrists prior to medication administration on one (1) out of one (1) observed inpatient care unit (The Acute Care Unit).

Findings:

Houlton Regional Hospital's policy titled, "Bedside Medication Verification," last revised 04/2024 states in part, "...The bar code on the medication package is scanned by the nurse. The nurse will verify correct drug, dose, route, and time completing appropriate pop-up screens. 4. The nurse then scans the bar code on the patient's wristband to ensure correct patient identification and the absence of contraindications..."

Houlton Regional Hospital's policy titled, "Medication Administration," last revised 11/2019 states in part, "...The following information will be known/verified each time a medication is given. a. Right patient identification (name, [Medical Record#], [Identification #], [Date of Birth]... e. Medication Carts will be locked at all times when not being used..."

On 02/10/2025 at 10:57 AM, observations were conducted on the Acute Care Unit accompanied by Infection Preventionist #1, a Registered Nurse ("RN"). On 02/10/2025 at 11:00 AM it was observed that a Computer on Wheels ("COW") also known as a Workstation on Wheels ("WOW") was in the hallway of the Acute Care Unit which was labeled, "Med COW 7." It was observed that a drawer on "Med COW 7," labeled, "324 [Patient #1 initials]" was left open and unsecured. It was observed that the unsecured drawer contained a patient identification wristband for Patient #1. RN #1 assisted in unlocking other drawers of "Med COW 7", and "Med COW 8," which was in the hallway directly next to "Med COW 7." It was observed that there were patient identification wristbands in the medication storage drawers for the following patients: Patient #2, Patient #3, Patient #4, Patient #5, Patient #6, Patient #7, & Patient #8.

During an in-person interview on 02/10/2025 at 11:05 AM with RN #2, they stated if there was a patient in a COVID or tuberculosis room, Nursing staff don't take the medication scanner into the patient's room. They stated that they will scan the bracelets in the drawer of the COW instead when administering medications.

During an in-person interview on 02/10/2025 at 11:23 AM with Licensed Practical Nurse ("LPN") #1 they stated that for patients on isolation, staff sometimes put bracelets out where they can scan them rather than bring the scanner into the room. LPN #1 stated, "Everyone is supposed to wear bracelets."

On 02/10/2025 at 11:24 AM, RN #2 stated, ""You wouldn't want the wand [scanner] going into a room where there is a patient with an infection."

During an in-person interview on 02/10/2025 at 1:24 PM, RN #3 stated that nursing staff don't bring the scanners into the isolation rooms because they don't want to contaminate the scanner. RN #3 stated they scan bracelets that are in the anteroom (a small room that leads to the isolation room where the patient resides). RN #3 stated the bracelets for isolation patients are attached to the wall of the anteroom. RN #3 stated the bracelets would be attached to the wall of the anteroom toward the window. RN #3 stated they scan the bracelet on the wall then scan the medications, then bring the medications into the room.

On 02/10/2025 at 2:32 PM observations were conducted on the Acute Care Unit accompanied by the RN Patient Care Coordinator. The RN Patient Care Coordinator indicated that there was a patient in room 306 who was on isolation precautions. The surveyor and the RN Patient Care Coordinator entered the anteroom of room 306. It was observed that the anteroom had an area for staff to don and doff personal protective equipment. It was observed that there was a large window that looked into the room where the Patient #9 was, and a door leading from the anteroom into Patient #9's room. It was observed that there was a patient identification wristband for Patient #9 taped to the window on the inside of the anteroom (located outside of the patient's room). Patient #9 indicated he/she was agreeable to speaking with the surveyor and the RN Patient Care Coordinator. Patient #9 stated that when they were administering medications, nurses would scan the bracelet taped to the window outside of his room, and not a bracelet physically located in his/her room or on his/her body.

During an in-person interview on 02/10/2025 at 2:39 PM, the RN Patient Care Coordinator confirmed that scanning bracelets that were taped to the walls of the hospital or located within the drawers of the COWs/WOWs prior to medication administration was not the hospital's policy and was not encouraged. They stated in the past they have found bracelets in the medication drawers of the COWs/WOWs. The RN Patient Care Coordinator confirmed on 02/10/2025 at 2:42 PM that extra patient identification bracelets should not be in the medication drawers of the COWs/WOWs. They stated the process for medication administration should be that the nurse goes in the Pyxis (medication dispensation machine), pulls out the medications, scans the patient's bracelet in the patient's room, then scans the medications and administers them. The RN Patient Care Coordinator stated the bracelet that is scanned for medication administration needs to be on the patient's body.

On 02/10/2025 at 2:53 PM an in-person interview was conducted with Respiratory Therapy Staff #1. Respiratory Therapy Staff #1 stated they did administer medications, and that they administer nebulizers. Respiratory Therapy Staff #1 stated they obtain the medication from the Pyxis, scan the patient's wrist band on their wrist, scan the medication, then document what they are doing. Respiratory Therapy Staff #1 stated that they were aware that a patient had a bracelet taped to their wall. Respiratory Therapy Staff #1 stated that the bracelet needs to be on the patient's wrist to ensure that you have the correct patient. Respiratory Therapy Staff #1 stated the risk the risk of scanning a bracelet that was not on the patient's body would be administering the wrong medication to the wrong patient. Respiratory Therapy Staff #1 stated that the scanner they use to scan medications can be cleaned with wipes after patient use.

On 02/11/2025 at 9:11 AM an in-person interview was conducted with Infection Preventionist #1. Infection Preventionist #1 stated that the scanners on the COWS can be cleaned with wipes. Infection Preventionist #1 stated the scanners can go into isolation rooms. Infection Preventionist #1 stated the risk of scanning a bracelet on the wall as opposed to scanning a bracelet on a patient's wrist would be medication errors - giving the wrong medications to the wrong patient.

On 02/11/2025 at 9:16 AM an in-person interview was conducted with the Nurse Manager of the Acute Care Unit. The Nurse Manager of the Acute Care Unit stated bracelets were being taped to the wall outside of the room and scanned prior to medication administration in the past. The Nurse Manager of the Acute Care Unit stated this occurred over 1 year ago (the date of the interview was 02/11/2025). The Nurse Manager of the Acute Care Unit stated his/her plan of action to prevent something like this from happening again was he/she, "told them that can't happen." He/she stated he/she told the staff after the past incident that the bracelets had to be on the patients. The Nurse Manager of the Acute Care Unit stated the standard is to have the bracelet on the patient. He/she stated that the risk of scanning a bracelet in the COW/WOW drawer or on the wall as opposed to scanning a bracelet on the patient's wrist is that it could be the wrong patient. The Nurse Manager of the Acute Care Unit stated that the scanners on the cows can be brought into isolation rooms and that they can be wiped down afterward. The Nurse Manager of the Acute Care Unit confirmed on 02/11/2025 at 9:20 AM that scanning was not always occurring at the bedside.

On 02/11/2025 at 10:30 AM an in-person interview was conducted with Respiratory Therapy Staff #2. Respiratory Therapy Staff #2 stated he/she has noticed staff on the Acute Care Unit putting bracelets in the drawers of the COWs/WOWs. Respiratory Therapy Staff #2 stated he/she has noticed staff on the Acute Care Unit taping bracelets to the wall. Respiratory Therapy Staff #2 stated it depends on the nurse, but they could have a bracelet on the wall and the nurse could have an additional bracelet in the COW/WOW. Respiratory Therapy Staff #2 stated he/she has witnessed a nurse on the Acute Care Unit scanning a bracelet that was not on the patients body prior to administering medication. Respiratory Therapy Staff #2 stated this happened as recently as the week of 02/02/2025 - 02/08/2025.

On 02/11/2025 at 10:44 AM an in-person interview was conducted with RN #4. RN #4 stated he/she has witnessed patient identification bracelets taped to the walls of the Acute Care Unit.

1. Based on document reviews, interviews, and observations, the hospital failed to ensure patient food was being stored in sanitary conditions, including failing to ensure food stored in patient refrigerators was labeled and dated, failing to ensure the food stored in patient refrigerators was not expired, and failing to ensure that food belonging to staff was not being stored with patient food items in three (3) out of four (4) observed patient food refrigerators (Emergency Department, Acute Care Unit and the main hospital kitchen.)

Findings:

Houlton Regional Hospital's policy titled, "Environment of Care Guidelines," dated 02/26/2020 states in part, "...Patient food and Staff food shall be stored in separate refrigerator units..."

On 02/10/2025 at 10:19 AM, observations of the Emergency Department kitchen revealed the refrigerator had two (2) white containers labeled, "Beef Stew," with no date on the containers. The refrigerator was also observed to contain a bowl full of an unidentified orange substance that was unlabelled and was not dated. This was brought to the attention of Housekeeper #1 who stated the items should not have been in the refrigerator.

On 02/10/2025 at 11:20 AM it was observed that the Acute Care Unit Patient Refrigerator contained a bowl of a white food substance with that was unlabelled and not dated. It was observed the refrigerator also had a "Vegetable Snack Tray With Dip," that was labeled with an expiration date of 02/07/2025 - indicating that it was expired. It was observed the refrigerator additionally contained an open bag of "Pepperoni" that was not labeled with an opened date. Certified Nursing Assistant ("CNA") #1 was present and was made aware of the unlabelled, undated, and expired items.

On 02/10/2025 at 11:51 AM, during an observation of the main hospital kitchen accompanied by the Kitchen Supervisor, it was observed that a fast-food restaurant iced coffee/tea beverage belonging to a kitchen staff member was being stored in a refrigerator containing patient food. The Kitchen Supervisor instructed the staff member to move the beverage to a different refrigerator intended for staff food.

2. Based on document reviews, interviews, and observations the hospital failed to ensure ultrasound and medical gels were labeled with the opened date and disposed of if/when expired, on one (1) out of two (2) observed patient care units (The Emergency Department).

Findings:

Houlton Regional Hospital's policy titled, "Ultrasound and Medical Gels," last revised 07/2014 stated in part, "...Ultrasound gel can be a potential source of infection if not used appropriately. In order to ensure the safe use and minimize the health risks associated with the use of ultrasound and medical gels these recommendations are made by the Infection Control Department... When opening a new gel bottle, date the bottle and discard unused gel after one month..."

On 02/10/2025 at 10:41 AM, during observations of the Emergency Department accompanied by Infection Preventionist #1, it was observed that the Emergency Department supply area had two (2) opened bottles of undated ultrasound gel which were present on the ultrasound carts, and one (1) opened bottle of undated ultrasound gel which was present on the shelf. All three (3) of the bottles of ultrasound gel had a sticker on the bottle which stated, "Date Opened [blank] Discard After 30 Days." No date was written in the blank "date opened" space. This was brought to the attention of Infection Preventionist #1 who confirmed these findings.

3. Based on document reviews, interviews, and observations, the hospital failed to ensure expired supplies were removed from circulation in one (1) out of two (2) observed medication rooms (the Acute Care Unit medication room).

Findings:

On 02/10/2025 at 11:27 AM, during observations of the Acute Care Unit medication room, an opened bottle of "Dyna-Hex 4 Chlorhexidine Gluconate 4% Solution" was observed which had a sticker that stated, "Discard After 1 Year," and had another sticker that stated, "Date Opened: 01/2024."

Infection Preventionist #1 was present for the observation and confirmed this finding.


4. Based on document reviews, interviews, and observations, the hospital failed to ensure patient medications were stored in a sanitary condition in one (1) out of two (2) observed medication rooms (the Acute Care Unit medication room).

Findings:

Houlton Regional Medical Center's policy titled, "Storage of Medications Brought In By Patients," last reviewed 05/15/2024 states in part, "...If a medication is brought into the hospital by a patient, it should be sent home with the patient's family. If the patient has no means to send a medication home it is to be packaged and stored in the pharmacy according to the following procedure and then returned to the patient at the time of discharge..."

On 02/10/2025 at 11:27 AM, during observations of the Acute Care Unit medication room, it was observed that a paper bag which was partially torn open was sitting directly on the floor of the Acute Care Unit medication room. Infection Preventionist #1, who was present for the observations, assisted the surveyor with looking into the bag and the bag was observed to contain three (3) boxes of lidocaine patches belonging to Patient #11.

Infection Preventionist #1 confirmed that this medication should not be stored directly on the floor.

5. Based on interviews, and observations, the hospital failed to ensure the patient lab specimen freezer in the hospital lab was maintained in a sanitary condition in one (1) out of one (1) observed laboratory areas (The main hospital laboratory).

Findings:

On 02/10/2025 at 11:47 AM, during observations of the main hospital laboratory accompanied by Infection Preventionist #2 (who was a member of the laboratory staff), an unidentified yellow substance on the bottom of the inside of the lab specimen freezer, and on the bottom of the shelf on the door of the lab specimen freezer. Infection Preventionist #2 confirmed these findings.