HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure a staff member's personnel record contained documentation of restraint training for one (1) of eleven (11) staff reviewed who had been involved in a patient restraint (Medical Doctor #1).

Findings:

The hospital's "Restraint and Seclusion" policy and procedure, last revised 1/28/2021, states in part, "All staff having direct patient contact with a patient in restraint will receive education and training upon hire and annually... Physicians and other AHPs will be provided education in order to maintain a working knowledge of this policy and appropriate order sets".

Medical Doctor ("MD") #1 ordered restraints for Patient #2R on 3/7/2022.

The surveyor requested to review MD #1's training records. The training record stated the MD had completed training on restraints on 1/17/2021. Based on the hospital's policy, the MD would be required to complete the next training on restraints on or before 1/17/2022.

As of 4/7/2022, there was no evidence provided to the surveyor that indicated the MD had completed training on restraints since 1/17/2021.

On 4/5/2022 at 1:13 PM, an interview was conducted with the Accreditation and Licensing Compliance Officer. She was asked about required training for the providers regarding restraints. She stated in part, "Restraint training is done annually...we assign it every year for Providers".

On 4/7/2022 at approximately 4:15 PM, the above finding was reviewed with the Accreditation and Licensing Compliance Officer.

Based on document reviews, observations, and interviews, the hospital failed to ensure rooms were cleaned within the Diagnostic Evaluation Area ("DEA") Unit of the Emergency Department ("ED") (Room #27 and #29).

Findings:

The Northern Light Health Eastern Maine Medical Center's policy with regard to Environmental Services titled "Scope of Services", last revised 6/30/2021, was reviewed. It states in part, "Environmental Services will provide the following services: Daily cleaning of in-patient rooms and support areas in accordance with predetermined schedules and work assignments...".

The "accountability sheet", that was completed by Nursing Leadership in the ED, was reviewed. This sheet stated it was completed by the Assistant ED Nurse Manager on 4/6/2022 at 10:15 AM and stated that all rooms were tidy

1. On 4/6/2022 between 10:30 AM and 11:45 AM, the following was observed in Patient #11's room in the DEA Unit (Room #29):
- A very large hole in the sheetrock of the wall. It has been there since at least 3/7/2022, when a work order had been placed for maintenance to repair;
- Sheetrock debris on the floor beside the bed;
- Two (2) pairs of dirty, used socks behind and on the side of the bed;
- Several used straws, straw wrappers, paper towels, and a cup on the floor;
- The floor had brown dried liquid areas, a large amount of visible dirt, and trash (e.g.: empty mask box, papers, stickers, post-it notes, etc.); and
- Two (2) used (what appeared to be) bloody band-aids.

On 4/6/2022 at 11:19 AM, an individual, who was usually with Patient #11 daily since admission, stated in part, "I have been here almost daily since [Patient #11] has been here [12 days] and I have not seen the room cleaned...The hole in the wall has been there since he/she arrived".

On 4/6/2022 at 3:03 PM, two (2) surveyors accompanied by the ED Nurse Manager and the Assistant ED Nurse Manager, toured the DEA to observe Room #29. The same observations that were made between 10:30 AM and 11:45 AM continued to be present at this time. The Assistant ED Nurse Manager stated in part, "I must have missed that room".

On 4/6/2022 at 3:07 PM, the ED Nurse Manager was asked who is responsible for cleaning patient rooms in the DEA. She stated in part, that they try to encourage patient accountability for cleaning their own room...Housekeeping does deep cleaning when the rooms are empty.

2. On 4/7/2022 at 10:57 AM, the following was observed in Room #27 in the DEA Unit:
- The Assistant Emergency Department ("ED") Nurse Manager was in Patient #12's room;
- There was some food on the floor, and the patient was asked by the Assistant ED Nurse Manager to pick up the food off the floor and throw it away;
- The patient complied with the Assistant ED Nurse Manager's request; and
- No handwashing was encouraged after the patient cleaned the floor.


On 4/7/2022 at 11:57 AM, an interview was conducted with the Nurse Infection Prevention and Control Manager. She was asked if the patients are expected to be involved with the cleaning of their room. She stated, "The patient? No." She was asked what the expectation is for the cleaning of patient rooms. She stated, I believe the environmental services staff go in daily to do the high touch areas...and would clean the room if it needed more.

On 4/7/2022 at 12:56 PM, an Environmental Services ("EVS") Supervisor was interviewed. She stated the following in relation to cleaning in the DEA:
- The housekeeper cleans the patient room after a patient leaves;
- The housekeeper would clean the floors in the common areas; and
- she would not expect the patient to be in charge of cleaning their own room.

On 4/7/2022 at 1:09 PM, EVS Employee #1 was interviewed. She stated that the only time that she goes into a patient room in the DEA to clean is when the patient is discharged.

On 4/7/2022 at 1:22 PM, an interview was conducted with Psychiatric Technician #1. He stated the following in relation to cleaning in the DEA:
- Psychiatric Technicians are responsible for cleaning the patient rooms;
- We either do it ourselves or may call housekeeping for assistance; and
- He stated that they get the patients to assist with cleaning the room as we want them to learn how to clean.

On 4/7/2022 at 1:49 PM, an interview was conducted with the Associate Vice President of Patient Care Services in the ED and Trauma. She stated, "They [nursing staff] are to assist in cleaning...they partner with the EVS team; We partner with EVS with daily room cleaning. Part of this is our communication tree...we work with our EVS staff...if things cannot be cleaned, they go right through the chain of command".

On 4/7/2022 at 4:15 PM, the above observations of Room #29 was reviewed with the Accreditation and Licensing Compliance Officer.

Based on document reviews, observations, and interviews, the hospital's Infection Preventionist failed to ensure the documentation of infection control rounds.

Findings:

Based on document reviews, observations, and interviews, the hospital failed to ensure rooms were cleaned within the Diagnostic Evaluation Area ("DEA") Unit of the Emergency Department ("ED") (Room #27 and #29). Please see A-0750 for details.

On 4/7/2022 at 11:47 AM, the Infection Prevention and Control Manager was interviewed in relation to infection control surveillance in the ED. She stated in part, "We are rounding and trying to talk with staff to see if there are any concerns. We try to round on the units once a week" and she stated documentation is completed.

Surveyors requested to review all of the available documentation of rounds for the ED. The documentation provided included two (2) dates (11/3/2022 [noted date error on form] and 3/31/2022). There was no evidence of weekly rounds for the ED that was provided.