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Based on observations and interviews with key personnel, it was determined that the facility failed to provide preventive maintenance programs to ensure that the facilities and patient-care equipment were maintained in a safe and sanitary condition.

Findings include:

1. On July 11, 2016, at 12:55 PM, two bowls and one steam table pan were observed in the kitchen to have been stacked when wet, creating a habitat for the growth of microorganisms.

This finding was confirmed at the time of the observation with the Kitchen Supervisor.

2. During a tour of the facilities on July 11, 2016, from 1:30 PM to 3:20 PM, with the Facilities Supervisor (F.S.) and on July 12, 2016, from 8:30 AM to 1:30 PM with the Plant Operations Director (P.O.D.), pull cords for call lights were observed to be too short to be reached by anyone who may have fallen to the floor in the following areas:

· Patient Rooms 105, 107, 108, 110, 111, 112, 113, 114, 117, 118, 120, 121, 122, 123,
· Mammography Changing Room,
· X-Ray Room 1 Restroom,
· Ultrasound Room Restroom,
· Emergency Department Restroom,
· Emergency Department Room 6 Restroom,
· The Postanesthesia Care Unit (PACU) Restroom.

These findings were confirmed at the time of the observations with the F.S. and the P.O.D.

3. During a tour of the facilities the surveyor observed that 2 ice machines failed to have an appropriate air gap on their discharge lines consistent with recommendations from The Centers for Disease Control and Prevention. The failure to install an air gap provides a direct connection to the waste water system, providing potential risk for contamination of the ice provided to patients.
In the Centers for Disease Control and Prevention weekly report titled "The Morbidity and Mortality Weekly Report" (MMWR) which provides recommendations and "Guidelines for Environmental Infection Control in Health Care Facilities: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee (HICPAC)," published on June 6, 2003, states that the ice machines need to be clean and disinfected on a regular basis and consistent with the manufacturer's instructions for cleaning. In addition, the facility must ensure that they "Install proper air gaps where the condensate lines meet the waste lines."

On July 11, 2016, between 1:30 PM and 3:20 PM, while conducting a facility tour with the Facilities Supervisor (F.S.), the surveyor observed that the ice machine located in the Medical/Surgical Department failed to have an air gap installed in its drain line. The F.S. indicated that he needed to research if this unit had an internal air gap that was not visible to the surveyor. On July 12, 2016 at 1:00 PM, the F.S. confirmed that the ice machine on the Medical Surgical Department did not have an internal or external air gap. On July 13, 2016 at approximately 9:00 AM, it was reported by the Director of Quality that the facility has ordered the parts necessary to create the required air gap.
· On July 12, 2016, from 8:30 AM to 1:30 PM, on a tour of the hospital with the Plant Operations Director (P.O.D.), it was observed that the ice machine located in the Emergency Department failed to have an adequate air gap installed in its drain line. The air gap was immediately repaired by the P.O.D.

4. During a tour of the facilities the surveyor observed rusted surfaces on equipment, creating uncleanable surfaces.
· While making observations of the Medical/Surgical unit with the Facilities Supervisor (F.S.) on July 11, 2016, between 1:30 PM to 3:20 PM, the surveyor and the F.S. observed rusty casters on an intravenous (IV) pole in Patient Room 112 .
· On July 12, 2016, at 8:45 AM, during a tour of the Emergency Department, with the Plant Operations Director (P.O.D.), a stretcher utilized for patient care was observed to have a rusted area under the mattress in Room 5.
· On July 12, 2016, at 12:45 PM, during a tour of Operating Room 2 with the P.O.D., an intravenous (IV) pole was observed to have rusty casters, and a hamper cart had a rusty area at its base.

These findings were confirmed at the time of the observations with the F.S. and the P.O.D.

5. During a tour of the Medical/Surgical unit on July 11, 2016, from 1:30 PM to 3:20 PM, the safety grab bars on the toilets were observed to have blistering and peeling paint on the section that passes over the back of the toilet, creating uncleanable surfaces. These were observed in a number of patient bathrooms, including Patient Rooms 107, 110, 111, 113, and 116.

These findings were confirmed at the times of the observations with the Facilities Supervisor.

6. During a tour of the facilities on July 11, 2016, from 1:30 PM to 3:20 PM, the surveyor observed missing wood finish, creating uncleanable surfaces in the following areas:
· On the walls in Patient Room 111.
· On the wooden trim of the television cabinet in Room 107.
· On the lateral chest stabilizer in X-Ray Room 2.

These findings were confirmed at the times of the observations with the Facility Supervisor.

7. During multiple tours of the facility the surveyor observed torn vinyl coverings on patient care equipment, creating uncleanable surfaces in the following areas:

· On July 11, 2016, at 2:55 PM, in the Remote Blood Draw Room, the draw chair, utilized for obtaining patient blood samples, had an arm support that had cracked vinyl. This finding was confirmed at the time of the observation with the Facilities Supervisor.

· On July 12, 2016, at 9:35 AM, in the Gym of Outpatient Rehabilitation Services, worn and cracked vinyl was observed on the Total Gym back pad and on the rebound device in the gym. These findings were confirmed at the time of the observations with the Plant Operations Director.

· On July 12, 2016, at 12:45 PM, during a tour of the Surgical Suite Equipment Storage Room, a limb support with a torn vinyl cover that had been taped, creating an uncleanable surface, was observed . This device was immediately removed from service by the Plant Operations Director.

The 2012 Perioperative Standards and Recommended Practices states: "Recommendation V.a. The quality of air entering the operating rooms should be carefully controlled. V.a.2. A minimum of 20% of the incoming air (i.e., three air exchanges per hour) should be from the outdoors. V.d.1. The minimum rate of total air exchanges per hour should be maintained at a constant level as follows: Operating room: minimum of 15 exchanges per hour with a recommended range of 20 to 25 air exchanges. Postanesthesia care unit: six air exchanges per hour. Sterile storage area: four air exchanges per hour."

The hospital "Environment Humidity, Air Temperature in Surgical Areas" Policy states: All procedure and surgical areas must... have a minimum of 15 air exchanges per hour... "


8. On July 11, 2016, a request was made for documentation verifying the number of air exchanges per hour.

· During several interviews with the Plant Operations Director (P.O.D), on July 11, 2016, he confirmed that the facility failed to maintain documentation regarding the number of air exchanges that occurred in any of the Surgical Suite areas. On July 12, 2016, at 3:00 PM, the P.O.D. confirmed that the facility failed to monitor the air exchanges occurring in the Operating Rooms.

· In an interview with the P.O.D. on July 13, 2016, at 8:50 AM, he stated that he had been in communication with the company that maintains their clean rooms about setting up a system for monitoring the air exchanges in the Operating Room area.

· The potential impact of the number of air exchanges not being performed based on established standards is that microbial or chemical contaminates might not be removed from the areas and/or the sterile field could become contaminated, therefore increasing the risk of surgical site infections.

9. During a tour of the facilities on July 12, 2016, the surveyor observed stained ceiling tiles, indicating water leakage and creating a habitat for the growth of microorganisms, in the following areas:
· The Waiting Room Restroom of Orthopedics and Surgical Services.
· Room 2 (Speech Therapy Room) of Outpatient Rehabilitation Services.
· In the Gym of Outpatient Rehabilitation Services.
· In Exam Room 4 of Outpatient Rehabilitation Services.

These findings were confirmed at the time of the findings with the Plant Operations Director.

· On July 12, 2016 at 1:30 PM, multiple stained ceiling tiles were observed in the Medication Room of the Medical/Surgical Unit. This finding was confirmed at the time of the observation with the Pharmacist.

10. On July 13, 2016, at approximately 8:45 AM, during a tour of the Surgical Services Department Sub-Sterile Room, it was observed that two "Patient Roller Boards" (devices that are used to transfer a patient between the operating table and stretcher prior to and after surgical procedures, which may be in direct contact with the patient), were stored on the floor when not in use, potentially causing them to become unsanitary.

This finding was confirmed by the Director of Surgical Services on July 13, 2016, at approximately 9:00 AM.

Based on tours of the facilities and interviews with key personnel, it was determined that the facility failed to keep the premises clean and orderly.

Finding Includes:
On July 12, 2016, from 8:30 AM to 9:45 AM, during a tour of Orthopedics and Surgical Services, multiple cardboard boxes were observed to be stored on the floor in the Janitors Closet, resulting in the inability to properly clean the floor and creating the potential for the cardboard to absorb moisture, creating a habitat for microorganisms to grow.

This finding was confirmed at the time of the observation with the Plant Operations Director.

On July 13, 2016 at 9:00 AM, it was reported by the Director of Quality that all the boxes had been removed from the Janitor's closet and stored appropriately.

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

Findings include:

A review of the hospital emergency plan was conducted on July 12, 2016 at 3:00 PM. It failed to identify the quantities of water that would be necessary to care for patients and staff during an emergency.

During an interview with the Food Service Director on July 12, 2016 at 3:00 PM, she stated it had not been determined how many people that the hospital would need to provide food and water for in case of an emergency. Therefore,the hospital failed to determine what an adequate supply would be. Additionally, she was unaware of any contracts with vendors to supply emergency food and water.

Based upon on-site 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 July 11, 2016, for the Maine State Fire Marshal's Office Life Safety Code survey.

Based on document review and interviews, it was determined that the facility failed to have an emergency plan to provide for an emergency supply of food and water.

Findings include:

On July 12, 2016 at 3:00 PM a review of the facility emergency plan was conducted. The plan fails to address how the hospital would procure food and water, or the amounts that would be needed during an emergency.

In an interview with the Director of Materials Management on July 12, 2016, at 11:15 AM, he stated that he was not aware of any contracts to supply emergency food or water to the hospital.

In an interview with the Food Service Director on July 12, 2016 at 3:00 PM, she stated it had not been determined how many people that the hospital would need to provide food and water for in case of an emergency, thus there was no way to determine what an adequate supply would be. Additionally, she was unaware of any contracts made with vendors to supply emergency food and water.

A review of the contract on with the hospital food vender on July 13, 2016, revealed that providing deliveries during emergencies was not included in the wording of the contract.

Based on document review and interview with staff, it was determined that the facility failed to maintain a complete and accurate medical record for three (3) of five (5) surgical records reviewed. (Record EE, Record FF, and Record GG)

The findings include:

1. A review of Record EE revealed that the "Pre-Op Anesthesia Record" document failed to contain documentation of the time that the Pre-Op Anesthesia assessment was conducted prior to the performance of the surgical procedure.

2. A review of Record FF revealed that the "Pre-Op Anesthesia Record " document found that the check box associated with the selection of " PT. MEETS CRH PACU/OPSU DISCHARGE CRITERIA NO APPARENT ANES. COMPLICATIONS," was not checked. The associated space was signed by the Certified Registered Nurse Anesthetist (CRNA) with a date/time of 6-9-16/1315.

3. A review of Record GG revealed that the "Pre-Op Anesthesia Record" document failed to contain documentation of the time or the year that the Pre-Op Anesthesia assessment was conducted prior to the performance of the surgical procedure.

These findings were confirmed by the Director of Surgical Services at the time of discovery on July 13, 2016, at approximately 11:50 AM .