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Based on review of medical records, review of the complaint/grievance log, review of the restraint log, review of individual grievances, review of policies and procedures and interviews with key staff August 5-6, 2014, it was determined that the facility failed to promote and protect each patient's rights. The evidence is as follows:


1. The hospital failed to provide a written response to each complainant after the resolution of each grievance (See Tag A-0123);

2. The hospital failed to provide a safe setting for care for all patients (See Tag A-0144);

3. The hospital failed to identify the least restrictive interventions that were tried prior to the application of restraints (See Tag A-0164);

4. The hospital failed to obtain physician's orders for all restraints (See Tag A-0168);

5. The hospital failed to ensure that patients were seen face to face within one hour after the initiation of restraints (See Tag A-0178);

6. The hospital failed to document the description of the patient's behavior and the interventions used in the patient's medical record (See Tag A-0185);

7. The hospital failed to ensure that the patient's medical record contained documentation of the patient's response to the restraint and the rational for continued use (See Tag A-0188);

8. The hospital failed to ensure that staff personnel records contained documentation of training and demonstration of restraint competency (See Tag A-0208); and

9. The hospital failed to report deaths associated with the use of seclusion or restraint (See Tag A-0213).

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

Based on review of the complaint log, review of policies and procedures, review of information provided and interviews with key staff August 5-6, 2014, it was determined that the facility failed in its resolution of the grievance to provide the patient with written notice of its decision that contained the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion.

Findings include:


1. Maine Coast Memorial Hospital policy titled, 'COMPLAINTS' stated, "PROCEDURE 4. The Quality Improvement Department will ensure an acknowledgment is provided to the complainant within 3-7 business days of the complaint being received in the Quality Department. This acknowledgment may be verbal or in writing, from the Quality Department or a manager. 6...... Resolution of complaints may take up to 90 days to complete depending on necessary reviews and input. The hospital will strive to maintain an overall average lapsed days for complaint resolution of 30 days with a goal of 7 days. The written response to the patient on Maine Coast Memorial Hospital letterhead will include: a contact person, steps taken on behalf of the patient to investigate the complaint, the results of the complaint process and the date of final response.

2. Six (6) complaints were reviewed on August 6, 2014. The following was found:

a. Complaint A was received on May 15, 2014. On May 16, 2014, a letter was sent to the complainant that stated a resolution would be done within 30 days. There was no documented evidence that the complainant received a written notice of the hospital's decision/resolution.

b. Complaint B was received on June 4, 2014. On June 5, 2014, a letter was sent to the complainant that stated a resolution would be done within 30 days. There was no documented evidence that the complainant received written notice of the hospital's decision/resolution.

c. Complaint C was received on July 18, 2014. There was no documented evidence that the complainant received an acknowledgment of the hospital's reciept of the complaint.

d. Complaint D was received on July 24, 2014. There was no documented evidence that the complainant received an acknowledgment of the hospital's reciept of the complaint.
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e. Complaint E was received on October 8, 2013. It was documented that a note was sent but there was no copy of the note.

f. Complaint F was received on April 1, 2014. On April 2, 2014, a letter was sent to the complainant that stated a resolution would be done within 30 days. There was no documented evidence that the complainant received written notice of the hospital's decision/resolution.


3. During an interview with the Quality Leader on August 6, 2014, at approximately 3:00 p.m., she confirmed that the above findings were accurate.

Based on review of medical records, review of information provided and interviews with key staff August 4-6, 2014, it was determined that the facility failed to ensure that each patient received care in an environment that a reasonable person would consider safe.

Findings include:

1. During tour of the Emergency Department, it was observed that one of seventeen (17) stretchers and 1 of three (3) commodes, lacked a documented weight posted on them.

2. The above finding was confirmed by the ICU/ED (Intensive Care Unit/Emergency Department) Nurse Manager and the on October 10, 2014 at approximately

Based on record review and interview with key staff on August 6, 2014, it was determined that the facility failed to utilize the least restrictive interventions prior to use of restraints for three (3) of six (6) restraint records reviewed. (Records: BB, CC and FF)

Findings include:

1. Physician's orders of restraint records BB, contained a form titled, 'physician orders-behavior management' which contained a question 'were alternative methods to prevent restraints attempted?' This box (yes or no) was not checked to indicate attempts to use less restrictive devices for patient. Nursing notes for restraint Record BB also lacked documentation by the nurse to indicate that less restrictive methods were employed prior to the use of restraints. The surveyor was unable to locate documentation anywhere else in the medical record to ascertain that any alternative method to prevent the use of restraints was attempted.

2. Physician's orders of restraint records CC, contained a form titled, 'physician orders-behavior management' which contained a question 'were alternative methods to prevent restraints attempted?' This box (yes or no) was not checked to indicate attempts to use less restrictive devices for patient. Nursing notes for restraint Record CC also lacked documentation by the nurse to indicate that less restrictive methods were employed prior to the use of restraints. The surveyor was unable to locate documentation anywhere else in the medical record to ascertain that any alternative method to prevent the use of restraints was attempted.

3. Physician's orders of restraint records FF, lacked the form titled, 'physician orders-behavior management' which staff would use to indicate if alternative methods to prevent restraints were attempted. Nursing notes for restraint Record FF also lacked documentation by the nurse to indicate that less restrictive methods were employed prior to the use of restraints. The surveyor was unable to locate documentation anywhere else in the medical record to ascertain that any alternative method to prevent the use of restraints was attempted.

4. The above findings were confirmed by the Intensive Care Unit/Emergency Department Nurse Manager on Augusta 6, 2014, at approximately 3:00 p.m.

Based on record review and interviews with key staff on August 6, 2014, it was determined that the facility failed to ensure that restraints were ordered by a physician or other licensed independent practitioner prior to use for two (2) of six (6) restraint records reviewed. (Records EE and FF)

Findings include:

1. Review of the Emergency Department restraint Records EE and FF, lacked documentation that the physician's order for the use of restraints was obtained prior to the application of restraints.

2. The above findings were confirmed by the Intensive Care Unit/Emergency Department Nurse Manager on Augusta 6, 2014, at approximately 3:00 p.m.

Based on record review and interviews with key staff on August 6, 2014, it was determined that the facility failed to ensure that the patient was seen face-to-face by the physician or Licensed Independent Practitioner (LIP) within one (1) hour of initiation of restraints for one(1) of six (6) restrained records reviewed. (Record: DD)

Findings include:

1. Record DD indicated that he/she had a physician's order for restraints for violent self destructive behavior at 11:56 p.m., on October 18, 2013. The physician progress notes for Record DD lacked evidence that the physician had seen the patient face-to-face (one) 1 hour after application of the restraints.

2. The above findings were confirmed by the Intensive Care Unit/Emergency Department Nurse Manager on Augusta 6, 2014, at approximately 3:00 p.m.

Based on record review and interviews with key staff on August 6, 2014, the facility failed to document a detailed description of the patient's behavior in order to demonstrate the appropriateness of the intervention /restraint used for six (6) of six (6) restraint records reviewed. (Records: AA, BB, CC, DD, EE and FF)

Findings include:

1. Review of the restraint Records AA, BB, CC, DD, EE and FF, indicated a lack of documentation of the patient's behavior and the type of restraint used.

2. The above findings were confirmed by the Intensive Care Unit/Emergency Department Nurse Manager on Augusta 6, 2014, at approximately 3:00 p.m.

Based on record review and interviews with key staff on August 6, 2014, it was determined that the facility failed to ensure that there was documentation in the medical record to indicate the patient's response to the restraint used and a description of the impact of the intervention on the patient's behavior, that warranted the use of the restraint for six (6) of six (6) restraint records reviewed. (Records: AA, BB, CC, DD, EE, and FF)

Findings include:

1. The restraint Records AA, BB, CC, DD, EE and FF, revealed a lack of descriptive evidence regarding what impact the application of restraints had on the behavior that warranted the use of restraints.

2. The above findings were confirmed by the Intensive Care Unit/Emergency Department Nurse Manager on Augusta 6, 2014, at approximately 3:00 p.m.

Based on review of personnel files and interviews with key staff, on August 6, 2014, the facility failed to ensure that training and demonstration of competency were successfully completed by hospital staff.

Findings include:

1. Review of the personnel files of ten (10) Registered Nurses (RN's), indicated that five (5) of the RN's lacked documentation of restraint training.

2. The above findings were confirmed by the Staff Education, Customer Service and Volunteer Coordinator on August 6, 2014, at approximately 2:30 p.m.

Based on record review and interviews with key staff on August 5, 2014, the facility failed to assure that the Centers for Medicare & Medicaid Services (CMS) and the State were informed on the death of a patient within 24 hours of the patient being restrained.

Findings include:

1. The medical record of Patient EE, indicated that he/she had been restrained at 9:15 a.m., on February 20, 2014, and the restraints were removed at 9:18 a.m. the same date. The patient expired on February 20, 2014, at 9:42 a.m. The facility lacked evidence that the death within 24 hours of restraint application was reported to CMS or the state agency.
2. The above finding was confirmed with the Quality Leader on August 6, 2014, at approximately 3:15 p.m., who stated "we didn't know that we had to report it if it happened in the Emergency Room instead of inpatient."

Based on a review of Maine Coast Memorial Hospital (MCMH), Emergency Department (ED) medical records, a review of policies and procedures, and interviews with key staff on August 5 to 7, 2014, it was determined that the hospital failed to meet the emergency needs of patients by not providing the necessary medical screening examination, and stabilizing treatment. These findings represent an Immediate Jeopardy violation to the patients seeking emergency treatment at Maine Coast Memorial Hospital (MCMH).


The evidence is as follows:

1. Maine Coast Memorial Hospital policy titled, 'Patient Rights and Responsibilities' stated, "....Every patient at MCMH has the right to: 1. Access to care and services..receive care, treatment, and services within the capacity and mission of MCMH.."

2. A review of MCMH policy titled, 'Emergency Room Transfer Policy' stated, "III. MEDICAL SCREENING REQUIREMENT..for any individual who comes to the Emergency Department and requests (or for whom a request is made) examination or treatment for a medical condition, MCMH shall provide an appropriate medical screening examination within its capabilities, including ancillary services routinely available to the hospital to determine whether or not an emergency medical condition exists.....VI. NONDISCRIMINATION 1. MCMH shall not refuse to accept an appropriate transfer of an individual who requires specialized capabilities or facilities which MCMH has available."

3. A review of Patient A's medical record August 5-6, 2014, revealed that he/she arrived at the ED by ambulance on August 2, 2014. The medical record stated that the history of present illness was burning and cramping in the left calf. The record stated that the Emergency Medical Services (EMS) crew reported that they were transporting a bariatric patient with left leg pain and that he/she had requested transport to MCMH due to his/her Primary Care Physician being there. Upon EMS arrival at the hospital ambulance bay area, the ED charge nurse exited the ED and entered the ambulance with the patient and EMS crew still inside. The ED charge nurse informed the EMS crew and the patient that MCMH did not have weight appropriate equipment to keep the patient and staff safe. The Emergency Department Physician then went out to ambulance and spoke with the patient to discuss transfer to Eastern Maine Medical Center. The ED physician did not conduct any medical assessment or screening. The ED physician completed a form for the Emergency Medical Treatment and Labor Act (EMTALA) and the patient was taken by EMS to EMMC. The patient never exited the back of the ambulance, and no medical screening or assessment was conducted.

4. Patient A's Emergency Room Report stated that the patient was sent to the ED from a residential home for evaluation of left calf pain of roughly 24 hours duration. The report also indicated that the patient had a stated weight of greater than 600 to 700 pounds. The ED record by the physician stated. "PHYSICAL EXAMINATION: Not performed beyond my talking to the patient in the ambulance." The surveyor noted that an adequate medical screening exam was not conducted and thus the need for stabilizing medical treatments could not be fully determined.


5. Additional medical records of Patient A's previous visits to the Emergency Department at Maine Coast Memorial Hospital were reviewed on August 5 and 6, 2014. The January 28, 2014, record revealed a four (4) day stay in the Emergency Department, and the surveyor noted that Patient A was seen and treated in the Emergency Department on February 10, 2014, and June 15, 2014 as well.

6. A telephone interview was conducted on August 4, 2014, at 2 p.m., with Patient A. He/She stated, "I had burning and cramping in my left calf since Friday and then on Saturday I still had it. ..I wanted to go to MCMH because I always go there.....The driver went into the Emergency department and was told to 'hold position'....a nurse came out and stated that it wasn't safe for me to be there. She said their equipment wouldn't hold me..the nurse made me feel very uncomfortable. She said she would get the supervisor and I said go ahead ...I was being polite but I was frustrated. They always take care of me there..[the doctor] came out and into the ambulance ..... he didn't check me out ...didn't take my vital signs and didn't look at my leg. He gave me his opinion that I would be in the Emergency Department at my own risk sitting in a wheelchair. He said the wheelchair was my only option and said it wasn't safe."

7. A tour was conducted in the Emergency Department on August 5, 2014, at approximately 9:00 a.m., the surveyor noted that there were seventeen (17) stretchers located in the Emergency Department. Twelve (12) of the stretchers were rated for 700 pounds. It was also observed that there was one (1) wheelchair in the hospital that had a weight capacity of 600 pounds. In an interview with the Charge Nurse on August 5, 2014 she confirmed that these same stretchers were in use on August 2, 2014

8. An interview was conducted on August 5, 2014, at 11:20 a.m., with the Emergency Department (ED) Charge Nurse who spoke with Patient A on August 2, 2014. The ED Charge Nurse stated that on August 2, 2014, EMS reported that Patient A had a weight of 600-700 pounds. The ED Charge Nurse stated, "The supervisor and I discussed this safety issue....I told [Patient A] that it would mean coming in at [Patient A's] own risk for safety ....I saw [Patient A] sitting on the foot of the stretcher at first and then standing in the ambulance...if the patient needed an ultrasound then [Patient A] would have to be on a stretcher ....my guess is that [Patient A] hadn't increased weight that much from the last time [Patient A] was here, but I went on what was stated as [Patient A's] weight ....I asked the patient and [Patient A] stated that the weight had not changed." There were no medical treatments ordered or provided to Patient A by MCMH staff.


9. A telephone interview was conducted on August 5, 2014, at 11:30 a.m., with the physician who spoke to Patient A in the ambulance on August 2, 2014. He stated, "The nursing supervisor came to me and said the ED equipment was not rated for [Patient A] and I asked how we handled this in the past. I was lead to believe that the stretcher would not hold [Patient A]." When asked if he had considered moving the stretcher from the ambulance to the Emergency Department, he stated that he had considered it, but he felt that he could not conduct a thorough exam in that manner. The ED Physician stated, "I made the conscience decision and it was a hard call. Could I safely evaluate [Patient A]..no, could I adequately evaluate [Patient A]..no..I had the feeling that I couldn't. Seemed like the best thing to do was to transfer [Patient A]."

10. An 'Interim Safety Plan' was received on August 5, 2014, at approximately 6:00 p.m. This plan was accepted by the Division and the Immediate Jeopardy was removed.