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Based on observations, interviews, and policy review, the hospital failed to ensure that juice was stored at the proper temperature in 1 of 3 treatment unit refrigerators (Outpatient Oncology Unit) and air exchangers were calibrated in 3 of 3 operating rooms (Operating Rooms #1, #2, #3).

Findings:

1. On 8/13/2018, at approximately 11:15 AM, the Kitchen Manager stated that juices arrive, at the hospital, either frozen or refrigerated. This would mean that the juices would need to be stored either frozen or refrigerated at proper temperatures after delivery.

At approximately 12:00 PM, the refrigerator in the Outpatient Oncology Unit was observed. There was no thermometer in this refrigerator and there was no evidence found that indicated the refrigerator temperature was being monitored to ensure the items in the refrigerator were being stored at the proper temperature. The Kitchen Manager took the temperature of a container of grape juice that was in the refrigerator and stated the temperature was 46 degrees Fahrenheit (F).

According to Section 3-501.16 of the State of Maine Food Code 2013, " ... Potentially Hazardous Foods (Time/Temperature Control for Safety Food) shall be maintained at 41 degrees F or less. Based on this information, the juice in the refrigerator of the Outpatient Oncology Unit was being stored above the required temperature of 41 degrees F or less; thus creating a potential for bacteria growth.

At the time of the observation, the Kitchen Manager stated that the kitchen staff did not monitor the Outpatient Oncology Unit and that volunteers were responsible for that refrigerator. The Director of Materials Management/Nutrition Services/Environmental Services stated that they had not coordinated the responsibility for monitoring the refrigerator temperature properly with the volunteers.

2. On 8/15/2018, a review of the Mayo Regional Hospital Environmental Controls Policy, # SS.POL.25 was completed. The policy indicated "HVAC performance will be monitored and maintained ...".

On 8/15/18 at approximately 11:00 AM, the Director of Engineering stated that the air exchangers in the operating rooms were last calibrated in 2015. He stated yearly calibration checks were to be done; however, this monitoring requirement was never implemented.

Based on this interview, the facility failed to ensure a preventative maintenance program was instituted for these air exchangers.

Based on observations and interviews, the hospital failed to have a system to ensure an ice machine had an air gap to prevent backflow of waste water and to ensure surfaces were maintained to ensure sanitation for 4 of 11 hospital areas (Obstetrics, Oncology, Emergency Department, and Surgical Services).

Findings:

1. On 8/13/18 at approximately 11:50 AM, on the Obstetrics Unit, and at approximately 12:00 PM, on the Oncology Unit, ice machines were observed and were noted not to have an air gap. An air gap is required to ensure that sewer waste does not back up through the drainage pipe, of the ice machine, into the ice machine; thus, contaminating the ice. These observations were confirmed with the Kitchen Manager at the time of the observation.

2. On 8/14/2018, between approximately 9:50 AM and 10:10 AM, the window sills of Rooms #3, #6, #7, #8, and #9 in the Emergency Department were worn and porous; thus, creating a surface that could not be easily cleaned and sanitized. These observations were confirmed with the Lead Maintenance Engineer at the time of the observations.

3. On 8/14/18, between approximately 1:10 PM and 1:20 PM, worn and porous surfaces were observed on the window sills of three rooms (#4, #5, and #6) in the Ambulatory Surgical Unit. In addition, worn and porous surfaces were observed on the wooden frames and/or arms of chairs located in three rooms (#4, #7, and #8) in the Ambulatory Surgical Unit. These worn and porous surfaces created surfaces that could not be easily cleaned and sanitized. These observations were confirmed with the Lead Maintenance Engineer at the time of the observations.