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Based on observation and interview, it was determined that the facility failed to ensure that patient medications and supplies had not expired and were safe for patient use.
The finding includes:
During a tour of the Emergency Department Triage Room 2 on November 7, 2016 at 10:30 am, the following was found:
· One single use bottle of Enfamil baby formula that expired August 1, 2016
· One unopened multi-dose bottle of Silipap drops (pediatric acetaminophen drops) which had expired August 2016
· This was confirmed at the time of discovery with the Emergency Department Nurse Director, who immediately disposed of both items.

Based on a tour of the kitchen, the facility failed to assure safe food handling practices.

Section 2-402.11 (A) of 2013 Maine Food Code states: " ...Food Employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, which are designed and worn to effectively keep hair from contacting exposed Food; clean Equipment, Utensils, and Linens; or unwrapped Single-Service or Single-Use Articles. "

The finding includes:

On November 7, 2016 at 11:00 AM, the Chef Manager and a Cook, were observed in patient food preparation areas, without hair restraints covering their facial hair.

This finding was confirmed with the Chef Manager at the time of the observation.

Based on tours of the hospital physical plant on November 7, 8, & 9, 2016, it was determined that the hospital failed to maintain the environment in such a manner as to assure the safety and well- being of patients.

Findings are:
· On November 7, 2016, the Sanford MRI van had a storage area that contained clean patient supplies, such as patient gloves and patient headphone covers, stored in the same area as a soiled broom, and floor mop. This was verified with key staffs during a physical plant tour on November 7, 2016.
· On November 8, 2016, the Sanford Campus Operating Rooms #1, #2, # 3, were found to have cracked wall tiles, worn varnished doors, door frames that were gouged, old white tape with pieces partially removed on stainless steel cabinets and peeling door signage requiring authorized personnel only. As a result, these areas are not easily cleaned and sanitized.
· The room between Operating Room #1 and #2, Sanford campus, had an area of exposed sheet- rock, a circular area on the floor covered with beige tape and there were dusty shelves. Sanford Operating Room findings were verified with key staff during the physical plant tour conducted on November 8, 2016.
· The overhead purple ceiling pipe cover in the Ambulatory Surgical center on the Sanford campus was dusty.
· The Emergency Code cart in the Sanford Emergency Department was not checked every 24 hours as required in the hospital policy, "Code Cart Location, Maintenance, Exchange & Contents." There was no documentation of code cart check for one Adult cart on 9/4 & 5, 2016 and no code cart check for a Pediatric cart and another Adult cart for 9/4/2106. This was verified with key staffs during a physical plant tour of the Sanford Emergency Department on November 7, 2016.
· The "Code Cart/Defibrillator Check" log for the Emergency Code cart located in an alcove adjacent to the Biddeford Campus MRI (Magnetic Resonance Imaging), [a machine used to create images of internal structures of the body], Room showed several days when the hospital staff failed to perform the daily checks. The log indicated that no checks were documented on May 8, 2016, May 23, 2016, October 6, 2016, October 17, 2016, and October 20, 2016. This was confirmed by the Manager of Radiology Services who stated that if the MRI suite is not being used, then no checks are performed. The cart is outside of the locked MRI suite and available to anyone in the radiology area.

· On November 8, 2016 on the Sanford campus, clean dietary carts were left to dry in the Dietary Department in an area with approximately a quarter inch standing water. Also stored in this area was a stack of plastic lids used to cover patient foods. This was verified with key hospital staffs at approximately 2 pm on November 8, 2016.



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Based on tours of the hospital physical plant on November 7, 8, & 9, 2016, it was determined that the hospital failed to maintain the environment in such a manner as to assure the safety and well- being of patients.
The finding includes:
· On November 7, 2016, the Sanford MRI van had a storage area that contained clean patient supplies, such as patient gloves and patient headphone covers, stored in the same area as a soiled broom, and floor mop. This was verified with key staffs during a physical plant tour on November 7, 2016.
· On November 8, 2016, the Sanford Campus Operating Rooms #1, #2, # 3, were found to have cracked wall tiles, worn varnished doors, door frames that were gouged, old white tape with pieces partially removed on stainless steel cabinets and peeling door signage requiring authorized personnel only. As a result, these areas are not easily cleaned and sanitized.
· The room between Operating Room #1 and #2, Sanford campus, had an area of exposed sheet- rock, a circular area on the floor covered with beige tape, and dusty shelving. Sanford Operating Room findings were verified with key staff during the physical plant tour conducted on November 8, 2016.
· The overhead purple ceiling pipe cover in the Ambulatory Surgical center on the Sanford campus was dusty.
· The Emergency Code cart in the Sanford Emergency Department was not checked every 24 hours as required in the hospital policy, " Code Cart Location, Maintenance, Exchange & Contents." There was no documentation of code cart check for one Adult cart on September 4-5, 2016 and no code cart check for a Pediatric cart and another Adult cart for September 4, 2106. This was verified with key staffs during a physical plant tour of the Sanford Emergency Department on November 7, 2016.
· The "Code Cart/Defibrillator Check" log for the Emergency Code cart located in an alcove adjacent to the Biddeford Campus MRI (Magnetic Resonance Imaging), [a machine used to create images of internal structures of the body], room showed several days when the hospital staff failed to perform the daily checks. The log indicated that no checks were documented on May 8, 2016, May 23, 2016, October 6, 2016, October 17, 2016, and October 20, 2016. This was confirmed by the Manager of Radiology Services who stated that if the MRI suite is not being used, then no checks are performed. The cart is outside of the locked MRI suite and available to anyone in the radiology area.

· On November 8, 2016 on the Sanford campus, clean dietary carts were left to dry in the Dietary Department in an area with approximately a quarter inch standing water. Also stored in this area was a stack of plastic lids used to cover patient foods. This was verified with key hospital staffs at approximately 2 pm on November 8, 2016.



Zabik, Jeffrey
Based on tours of the hospital physical plant on November 7- 9, 2016, it was determined that the hospital failed to maintain the environment in such a manner as to assure the safety and well- being of patients.

The finding includes:

· On November 7, 2016, from 10:30 AM to 11:15 AM, during a tour of the kitchen with the Chef Manager, the kitchen ice machine was observed with rust on the interior surface of the ice bin, creating a surface not eaisl;y cleansed and sanitized, therefore potentially creating a risk of contamination of the ice in the bin.

· On November 7, 2016 from 11:15 AM to 12:30 PM, during a tour of the facility with the Risk Management Specialist (RMS) and the Vice President of Facilities (VPF) the following was observed.

- Medical/Surgical 4th floor (MS4) Wheelchair Alcove: Two wheel chairs with arm pads with non-intact surfaces unable to be properly cleansed or sanitized.

- MS4 Storage Room: 6 Intravenous (I/V) pole with missing paint and rusty bases unable to be properly cleansed or sanitized.

- Special Care Unit (SCU) Rooms 401, 402, 403, 405, 417, 420, 421, 422, 423, and 424: high dust on the top surface of the lift rails and on the surface of the top border of the white board.

- SCU Room 402: One I/V pole missing paint and rust on the base, unable to be properly cleansed or sanitized.

- These observations were confirmed at the time of the observations with the RMS and the VPF.

· On November 7, 2016 from 1:00 PM to 3:30 PM during a tour of the facility with the Risk Management Specialist (RMS), the Vice President of Facilities (VPF), and the Director of Environmental Services (DES), the following was observed:

- In SCU Room 428: High dust on the top surface of the lift rails and on the surface of wall molding.

- SCU 435: High dust, on top of the cabinet doors. Rust and missing paint on the bottom of the bathroom door frame, and one I/V pole with rust and missing paint on its base, unable to be properly cleansed or sanitized.

- MS4 South Restroom: Call light cord tied up, rendering the call light unusable to anyone who may fall to the floor.

- Seclusion Room: Entry has duct tape on an approximate 6 inch by 12 inch area of floor and is unable to be properly cleansed or sanitized.

- Medical Surgical, 3rd floor, (MS3) Room 303: High dust on the top surface of the light in the bathroom.

- MS3 Rooms 305, and 307: High dust on top surface of the lift rails and on the top of the cabinet doors.

- MS3 Clean Equipment Room: One crutch was observed with worn, cracked arm pad, unable to be properly cleansed or sanitized.

- MS3 Room 322: High dust on the top border of the white board and on the top of the cabinet doors.

- MS3 Room 318: High dust on the top border of the white board and on the top surface of the light in the bathroom.

- MS3 Room 336: High dust on the wall mounted light over bed 2.

- MS3 Room 334: High dust on the top of the cabinet.

- MS3 Shower room: An unidentified brown residue was observed on the edge of the floor of the shower.

- MS3 Room 340: High dust was observed on the top surface of the linen closet doors.

- Work Place Health Clinic 2: High dust on the on top of the cabinet.

- Cardio-Rehabilitation Area: Men's shower curtain with black, mold-like stains on the bottom edge.

- These observations were confirmed at the time of the observations with the VPF and/or the DES.

· On November 8, 2016, from 8:45 AM to 11:00 AM, a tour of the hospital with the Risk Management Specialist (RMS), the Vice President of Facilities (VPF), and the Director of Environmental Services (DES), the following was observed:

- Emergency Department (ED) Exam Room 2: High dust on the top surface of the lamp over the bed and the wall-mounted scope holder. One hamper stand has an unidentified residue on its base.

- ED Exam Room 3: High dust on the top of the cabinet and on the wall mounted bag holder.

- ED X-Ray Room: One hamper stand has an unidentified residue on its base.

- ED Exam Room 12: High dust on the wall-mounted scope tip holder and the wall-mounted x-ray light box. One hamper stand has an unidentified residue on its base.

- ED Exam Room 14: High dust on the wall-mounted x-ray light box. One hamper stand has an unidentified residue on its base. One stretcher mattress with a non-intact surface unable to be properly cleansed or sanitized. One fabric sheet with an approximately 2 inch diameter area of glue residue unable to be properly cleansed or sanitized.

- ED Clean Supply Room: One IV pole with a rusty base, unable to be properly cleansed or sanitized.

- ED Orthopedic Storage Room: One pair of crutches with visibly soiled arms pads.

- ED Exam Room 23: One stool with rusty castors unable to be properly cleansed or sanitized.

- ED Fast Track Procedure room: Damaged, non-intact surface of support column unable to be properly cleansed or sanitized.

- Wound Clinic Bathroom: Unfinished portion of wall near the toilet base unable to be properly cleansed or sanitized.

- Nuclear Medicine: Entry door has a damaged and splintered edge, creating a non-intact surface unable to be properly cleansed or sanitized.

- Radiology Department (RD) Ultrasound Room 2: One hamper stand has an unidentified residue on its base.

- RD Computer Tomography Room: One positioning wedge with non-intact surface unable to be properly cleansed or sanitized. One hamper stand has an unidentified residue on its base.

- Wound Clinic: Two crutches were observed to have non-intact surfaces unable to be properly cleansed or sanitized.

- These observations were confirmed at the time of the observations with the VPF and/or the DES.

· On November 8, 2016, at 11:30 AM, at the Sports Performance Center, at 12 Thornton Avenue, Saco, one stool was observed with rusted surfaces unable to be properly cleansed or sanitized. This was confirmed at the time of the finding with the VPF

· On November 8, 2016 at 1:00 PM, at Physicians Orthopedic office at 46 Barra Road, Biddeford, Therapy Room 6: One traction bar with a torn hand grip unable to be properly cleansed or sanitized. This was confirmed at the time of the observation with the VPF.

· On November 8, 2016 at 1:40, at Physicians Pediatrics at 9 Healthcare Drive, Biddeford, in Exam Room 9: One exam table with a non-intact surface unable to be properly cleansed or sanitized.

· On November 9, 2016, during a tour of Surgical Services was conducted starting at 6:05 AM with the Surgical Services Director (SSD), the following was observed:

- Operating Room (OR) 4: Arthroscopy cart with rusty casters unable to be properly cleansed or sanitized.

- OR 3: One bucket with a cracked rubber ring and rusty wheel casters, one IV pole missing paint, operating table base has glue residue, tape residue on multiple cabinets, all creating surfaces that are unable to be properly cleansed or sanitized.

- OR 1: One bucket with a cracked rubber ring, multiple stools and I/V poles with rusty casters, 2 stools with missing paint, tape on walls and on the anesthesia cart, all creating surfaces that are unable to be properly cleansed or sanitized.

- OR 6: Cytology, a wall-mounted speaker with a porous cover unable to be properly cleansed or sanitized. Multiple damaged areas of the wall under the clock and tape on another wall, multiple I/V poles with rusty castors and missing paint surfaces, all creating surfaces that are unable to be properly cleansed or sanitized.

- OR 7: One bucket with a cracked rubber ring, a wall-mounted speaker with a porous cover unable to be properly cleansed or sanitized. Two stirrup pads with worn surfaces, two I/V poles and table with rusty castors, all creating surfaces that are unable to be properly cleansed or sanitized.

- OR 5: A ring stand and two tables with rusty casters, unable to be properly cleansed or sanitized.

- Endoscopy Room 3: One positioning wedge with a non-intact surface and one I/V pole with rusty castors unable to be properly cleansed or sanitized.

- OR 2: Rusty stools unable to be properly cleansed or sanitized.

- In the Ambulatory Care Unit (ACU): Patient refrigerator with ice buildup creating a potential for overheating and/or failure of the unit.

- Recovery Room 1: One oxygen tank stand with a rusty base unable to be properly cleansed or sanitized and one hamper stand with an unidentified residue on its base.

- In the Post-Anesthesia Care Unit 2 kitchenette: Ice machine has insufficient "air gap " , which could possibly allow drain fluid to flow back into the ice machine.

- ACU 1: One wheel chair arm pad with a non-intact surface unable to be properly cleansed or sanitized.

- Mammography: One hamper stand has an unidentified residue on its base.

- These findings were confirmed at the time of the observations with the VPF.

Based upon on-site observations, interviews, and document reviews conducted by Life Safety Code surveyors, it was determined that the General & Specialty Hospital was not in full compliance with 42 CFR §482.41(b), the Life Safety Code.

Please see the Life Safety violations cited on the Centers for Medicare and Medicaid Services (CMS) form 2567 dated November 10, 2016, for the Maine State Fire Marshal's Office Life Safety Code survey.

Based on observation, document review and interview, it was determined that the facility failed to ensure that infection control policies were followed.
The Infection Prevention and Control Policy "Exposure Control Plan" states "Staff food and beverages are allowed in cafeteria, staff lounges, and break rooms only."
The Operating Room Policy and Procedure "Surgical Attire for Personnel" states "Large bags, backpacks, suitcases or other personal clothing, etc ...are not to be carried into the semi-restricted or restricted areas ..."
The finding includes:
On November 8, 2016 at 10:00 am , during a tour of the semi-restricted Procedure Room 4, where endoscopic procedures are performed,the following items were observed in a cabinet :
· One half empty Dunkin' Donuts iced coffee
· An empty coffee cup
· An empty reusable beverage container with a reusable straw
· An open Minute Maid juice bottle
· A staff member's handbag
· A staff member's tote bag, which contained personal belongings. Wrapped candy was easily visible within the bag.
· 4 bottles of staff medication (ibuprofen and acetaminophen)
These observations were immediately confirmed with the Department Manager, who explained that these items were owned by staff members, and that it was against hospital policy for staff to have personal belongings, food and beverages in the procedure room.
During a return tour at approximately 1:00 pm, the personal belongings had been removed from the cabinet.

Based on document review and interview on November 8, 2016 at 1200 pm, it was determined that the facility failed to ensure that informed consent was obtained prior to non-emergency anesthesia administration in one of three surgical records reviewed. This finding was confirmed at the time of discovery by the Surgical Services Manager. On November 9, 2016, it was again confirmed that hospital personnel were unable to locate the anesthesia consent form. (Record I)