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Based on review of policies and procedures, review of the complaint/grievance log, review of information provided and interviews with key staff on December 13, 2012, it was determined that the facility failed to follow their own grievance process as it related to the time frames specified in their policy, in (3) three of (5) five grievances.

Findings include:

1. The Southern Maine Medical Center policy titled, ' Complaint and Grievance Resolution Policy', stated, ".....in the event that a grievance requires extensive investigation that cannot be completed within 7 days, the hospital will inform the patient/representative that they are still working on a resolution and will follow-up with a written response within 10 work days."

2. On December 12 and 13, 2012, the surveyor reviewed the documentation of (5) five grievances chosen randomly from the grievance log. Grievances A, B and C did not have documentation that a written response had been sent to the patient/representative within 10 work days.

3. These findings were confirmed by the Risk Management Coordinator on December 13, 2012.

Based on review of clinical records and interviews conducted on December 12 and 13, 2012, it was determined that the hospital failed to have orders for restraints in two (2) of three (3) clinical records when behavioral restraints were utilized.

Findings include:

1. Record I contained an order for seclusion, but not an order for restraints. Nursing documentation in the clinical record indicated that four-point restraints were utilized for Patient I.

2. Record K contained an order for 15 minute checks while in restraints, but not an order for the restraints. Nursing documentation in the clinical record indicated that restraints were utilized for Patient K.

3. During interviews on December 12 and 13, 2012, these findings were confirmed with the Accreditation and Regulatory Coordinator and the Director of Quality and Risk Management.

Based on observations and interviews with key personnel on December 11, 2012, it was determined that the hospital failed to store all drugs and biological's in a secure area.

Findings include:

1. On December 11, 2012, a surveyor observed medications which were stored in unlocked refrigerators off hallways and in a cabinet without a lock in Lab #3 in the PrimeCare Physician Services - Pediatrics.

2. This finding was confirmed with the Office Manager and the Accreditation and Regulatory Coordinator on December 11, 2012.

Based on observation and interviews with key personnel on December 11, 2012, it was determined that the hospital failed to assure that the physical plant and environment was maintained for the safety and well-being of patients.

Findings include:

1. During a tour on December 11, 2012, a surveyor observed a refrigerator for the storage of laboratory specimens on a counter where medications were prepared for administration and next to a medication refrigerator in the PrimeCare Physician Services - Pediatrics.

2. This finding was discussed with the Office Manager and the Accreditation and Regulatory Coordinator on December 11, 2012.

Based on observations and interviews with key personnel on December 11, 2012, it was determined that the hospital failed to maintain equipment and supplies to ensure an acceptable level of safety and quality.

Findings include:

1. On December 11, 2012, a surveyor observed empty linen bags and a box containing a scale on the floor of the linen closet in PrimeCare Physician Services - Cardiology. This finding was confirmed with the Office Manager and the Accreditation and Regulatory Coordinator on December 11, 2012.

2. On December 12, 2012, a surveyor observed the painted walls were chipped/scraped in Room number nine (9) in the Acute Care Unit and Rooms one (1) and twenty (20) in the Emergency Department.

3. On December 11-12, 2012, a surveyor observed, the air gap in the ice machines in the Emergency Department and the Special Care Unit was not wide enough to ensure proper protection.

4. Citation numbers 2 and 3 were confirmed with the Vice President of Support Services on December 12, 2012.

5. On December 13, 2012, a surveyor observed there was rust on the casters and some table legs in all the Operating Rooms and the Cysto Room.

6. On December 13, 2012, a surveyor observed the cove base was chipped inside the door of the Operating Room #2.

7. On December 13, 2012, a surveyor observed the brass faucet nozzle was green from oxidation in the Cysto Room.

8. On December 13, 2012, a surveyor observed the exterior door frames of the Operating Rooms had chipped paint on their door frames

9. On December 13, 2012, a surveyor observed ceiling tiles were stained in the Operating Room clean supply room and the Anesthesia Prep Room.

10. On December 13, 2012, a surveyor observed there were rusty casters on equipment in the operating clean supply room. The was rust on the top of the two filing cabinets beside the desk in the Anesthesia Prep Room.

11. Citations 5 - 10 were confirmed with the Facility Manager on December 13, 2012.

12. On December 12, 2012, a surveyor observed a ceiling tile was stained and damaged in a janitor's closet outside the Pediatrics Unit. This finding was confirmed with the Vice President of Support Services.

13. The facility Infection Control Policy " IPCM 9108 " " Handling Clean and Sterile Supplies " which stated: " It is the responsibility of each health care worker to assess each package and its contents to assure that proper storage and handling conditions have been maintained. " ... " B. Items purchased as sterile should be used according to manufacture ' s directions. This may be either a designated expiration date, or a day-to-day expiration date such as ' sterile unless the integrity of the package is compromised. " '

14. The policy did not address who was responsible for tracking and removal of expired supplies from the nursing unit supply rooms.

15. This finding was confirmed by the Quality Manager Infection Control Registered Nurse on December 13, 2012.

16. During a tour of the Special Care Unit supply/medication room on December 11, 2012, three (3) bottles of Perative 1000 milliliter (ml) with expiration date of " 1NOV2012 " , one (1) #4 French Super Sheath catheter, with expiration date of 8/2012, and one (1) #6 French Super Sheath catheter, with expiration date of 9/2012, were observed in the current supply stock. This was confirmed by the Clinical Nurse Specialist on December 11, 2012.

17. During a tour of the Medical Surgical nursing units medication/supply rooms on December 12, 2012, two (2) bottles of Perative 1000 ml with expiration date of " 1NOV2012 " were observed in the 3rd floor nursing unit supply stock, and thirteen (13) bottles BacT/Alert FA 30 ml with expiration date of 12/05/12 was observed in the 4th floor unit supply stock. This was finding confirmed by the Medical/Surgical Nurse Manager on December 12, 2012.