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Based on observations and interviews, the hospital failed to ensure that patient care equipment was safe for patient use in 4 of 7 inpatient care areas (Intensive Care Unit, Emergency Services, Medical/Surgical Unit, and Surgical Services) and 1 of 7 outpatient units (Urology Clinic).

Findings include:

1. On June 13, 2017, at approximately 1:00 PM and at 2:30 PM, a sticker was observed on an intravenous (IV) pump in Suite 13/14 of the Intensive Care Unit and an IV pump in Room 6 of the Emergency Services Department). The sticker on each of these pumps indicated the pump was due for a safety inspection in March, 2017.

2. On June 13, 2017, at approximately 1:10 PM and approximately 2:00 PM, a sticker was observed on a bed in Patient Room 105 and on a bed in Patient Room 110. The sticker on each of the beds indicated the bed was due for a safety inspection in May, 2017.

3. On June 13, 2017, at approximately 3:00 PM, a sticker was observed on a Ranger fluid/blood warmer in Operating Room 2. The sticker indicated the warmer was due for a safety inspection in February, 2017.

4. On June 13, 2017, at approximately 3:45 PM, a baby scale was observed in Room 1 of the Urology Clinic in Suite 3 of an outpatient unit. The sticker indicated the scale was due for a safety inspection in April, 2017.


The above findings were confirmed with the Electrician at the time of the observations.

Based on observation and interview, the facility failed to ensure that trash was properly stored and secured outside by a covered dumpster for 1 of 1 dumpsters.
Finding:

On June 13, 2017, at 2:40 PM, the surveyor observed that the upper lid of the garbage dumpster was missing.

This observation was confirmed with the Electrician at the time of the observation.

Based on observations and interviews, the hospital failed to ensure the facility was maintained in a manner to promote cleanliness in 5 of 16 hospital areas (Linen Services, Cardio-Rehabilitation, Laboratory, Medical/Surgical Unit, Infusion Treatment) and 2 of 4 outpatient areas (Suite 1 and Suite 3 of the medical office building)

Findings include:

1. On June 13, 2017, between 11:20 AM and 12:50 PM, stained ceiling tiles were observed in the following locations: above dryer #1 in the linen room; in the Janitor's Closet in the Emergency Department; and over the Panda Warmer in the Cardiopulmonary area. These stained tiles indicated past water leakage and created a habitat for mold growth.

2. On June 13, 2017, between 12:30 PM and 1:45 PM, damage to the wall was observed in the following areas: in the Computed Tomography Room; in the cardiopulmonary gym; and in Patient Rooms 113, 115, 118, and 120. These damaged walls created a surface that could not easily be cleaned and sanitized.

3. On June 13, 2017, at 12:50 PM, a Life-flight stretcher with peeling paint was observed in the cardiopulmonary gym. The peeling paint created a surface that could not easily be cleaned and sanitized.

4. On June 13, 2017, at 12:55 PM, an unsealed crack extending across the floor was observed in the cardiopulmonary gym. The crack created a surface that could not easily be cleaned and sanitized.

5. On June 13, 2017, at 12:58 PM, an approximately three foot long strip of missing paint and damage to the wall was observed in Patient Room 102. The missing paint and wall damage created a surface that could not easily be cleaned and sanitized.

6. On June 13, 2017, at 1:35 PM, five crutches, with worn and cracked arm pads, were observed in the supply closet at Station 2. The worn and cracked arm pads created a surface that could not easily be cleaned and sanitized.

7. On June 13, 2017, at 1:45 PM, the corner of the counter was observed to be chipped, with exposed fiberboard type material, in the Infusion Room near the Pharmacy. The chipped area created a surface that could not easily be cleaned and sanitized.

8. On June 13, 2017, between 12:58 PM and 1:30 PM, a significant accumulation of dust was observed in the following locations: on the top surfaces of the lights over the beds in Patient Rooms 114 and 118 and on the top edge of the white boards in Patient Rooms 114 and 121

9. On June 13, 2017, at 1:10 PM, a corkboard was observed attached to the wall in Patient Room 105. The Electrician stated, to the surveyor, that most of the Patient Rooms have these corkboards. Corkboards have porous surfaces which have the potential to harbor microorganisms.

On June 14, 2017 at 3:00 PM, the surveyor requested information, from the Director of Plant Operations, regarding how the hospital was ensuring that the corkboards were sanitized.

On June 15, 2017 at 9:30 AM, the Director of Plan Operations stated that he did not have any information on whether the corkboards could or could not be sanitized.


The above findings were confirmed with the Electrician at the time of the observations.

Based on document review and interview, the facility failed to have an emergency plan to provide for sufficient potable water for patients and staff during an emergency.

Finding:

On June 14, 2017 at 12:15 PM, a review of the hospital emergency plan was conducted. The plan failed to identify the quantities of water that would be necessary to care for patients and staff during an emergency.

On July 14, 2017 at 12:20 PM, the Food Service Director stated, to the surveyor, that it had not been determined how much water they would need in case of an emergency.

On June 15, 2017 at 9:30 AM, the Food Service Director provided a surveyor with a document entitled "Plan of Correction, Nutrition and Food Services, 6/14/17", which states " ...the policy did not explicitly state required par levels for water and did not include estimates of water needed for an emergency."

Based on observations, interviews, and document reviews conducted by Life Safety Code surveyors, it was determined that the Critical Access Hospital was not in full compliance with 42 CFR §483.70(a), the Life Safety Code.

Please see the Life Safety violations cited on the Centers for Medicare and Medicaid Services (CMS) form 2567, dated June 13, 2017, for the Maine State Fire Marshal's Office Life Safety Code survey.