HospitalInspections.org

Based on document reviews and interviews, the hospital failed to ensure that medications were reconciled for one (1) out of (1) outpatient clinic patients reviewed (Patient #3).

Findings:

The MaineHealth "Medication Reconciliation" policy (not dated) states in part, "A complete list of a patient's current medications, allergies and sensitivities will be obtained and documented at all relevant encounters and sites of care...

The medication history is completed at all visits whenever medications are administered, prescribed or included in the care or service provided...

The patient's current medication history will be completed using all available resources including the patient, families, caregivers, residential facility, pharmacies and providers..."

On 09/24/2024 at 2:30 PM, medical records were reviewed with the Clinical Informatics Specialist. This review revealed the following:
-Patient #3's medical record contained no documented evidence that a medication history was obtained at an outpatient clinic visit on 6/25/2024.

On 09/26/2024 at 9:28 AM, the Senior Director of Accreditation confirmed that Patient #3's medical record visit to the outpatient clinic on 06/25/2024 had no documentation of a medication reconciliation completed as required by hospital policy.

Based on documentation reviews and interviews, the hospital failed to ensure that the medical record contained accurate information for one (1) out of eleven (11) reviewed patients (Patient #3).

Findings:

MaineHealth "Documentation Standards for the Legal Health Record" Corporate policy, dated 05/2023 states in part, "When an error is made in a medical record entry, proper error correction procedures must be followed...

...For Electronic Medical Records: When correcting or making a change, the original entry should be viewable, the current date and time should be entered, the person making the change should be identified, and the reason should be noted. In situations where there is a hard copy printed from the electronic record, the hard copy must also be corrected...

...Electronic Documentation: the medical record should only contain documentation that pertains directly to the patient."

On 09/24/2024 at 2:30PM, medical records were reviewed with the Clinical Informatics Specialist. This review revealed the following:
-Patient #3 and Patient #11's had the same first and last name;
-Patient #11's medications, allergies, encounters from outside facilities and medical history was included in Patient #3's medical record; and
-The electronic medical record was not consistent with the hard (printed) copy of Patient #3's medical record.

On 09/25/2024 at 2:30pm, an interview was conducted with the Health Information Manager. She/He believed the problem, after investigating the concern, was from the information network that may have merged Patient #3 and #11's medical record.

On 09/26/2024 at 9:28 AM, an interview was conducted with the Senior Director of Accreditation. She/he stated that upon further review, it was identified that a staff member had uploaded medical information into the incorrect patient's chart and there was no network error. In addition, corrected information in the electronic and hard copy record were not completed in accordance with the policy until after the date of the initiation of the survey (09/24/2024).

Based on document reviews, interviews, and observations, the hospital failed to ensure Sterile Processing Department (SPD) staff performed Ultrasonic Cleaning, a required step of the sterilization process, in one (1) out of two (2) observed Sterile Processing Departments (Portland).

Findings:

The STERIS InnoWave Unity and Unity 20 Sonic Irrigators (Ultrasonic Cleaner used in the Portland Location) Manufacturer Operator Manual states in part, "... Intended Purpose of Equipment The STERIS InnoWave (Trademark) Unity Sonic Irrigator is designed to thoroughly clean (remove tissue, blood, and other contaminants from) a variety of reusable surgical instruments. Cleaning is achieved through a combination of ultrasonic cavitation and low- frequency cannulated pulse enhancement (CPE) fluid recirculation to dislodge and flush away unwanted debris from both the outside and inside surfaces (hollow instruments only) of items placed in the tank..."

Maine Medical Center, Bramhall Campus's Standard Operating Procedure titled, "Sterile Processing Department, Maine Medical Center, Bramhall Campus Job Tools: Standard Operating Procedures (SOP) - Decontamination," states in part,"...Unless an item is incompatible, all trays must be placed in the ultrasonic cleaner..."

On 09/25/2024 at 11:17 AM, Sterile Processing Staff #1 stated the following:

- They feel like things are rushed;
- They must perform ultrasonic cleaning on very heavily contaminated trays;
- A lot of people skip the ultrasonic cleaning process; and
- The ultrasonic cleaning step is very important for patient safety.

On 09/25/2024 at 11:33 AM, Sterile Processing Staff #2 stated the following:

- To "ultrasonic something" means putting the equipment to be sterilized into a machine that makes ultrasonic cavitation bubbles, or vibration, to remove contamination;
- There are staff that skip the ultrasonic step;
- The equipment needs to go into the ultrasonic because that was the process.

On 09/25/2024 at 12:17 PM, Sterile Processing Staff #3 stated the following:

- We recently had five (5) trays sent back because they found adhesive or bioburden (viable microorganisms);
- Most of the time it is the same people who are just more or less dunking their trays in, doing a quick inspection and just sending it through the wash;
- Some trays that are really needed, and they can't be sent through sterilization because they are dirty so they must get sent back to the staff in the sink area, which takes more time;
- I have complained before and [the management of the Sterile Processing Department] says they will take care of it; however
- We are still seeing dirty trays.

On 09/26/2024 at 10:33 AM, Sterile Processing Staff #4 stated the following:

- If I received a tray in [decontamination] that was clearly not used in surgery, I have been told that it was alright if I just took [the tray] apart and manually cleaned it; and
- I wouldn't put it in the ultrasonic cleaner.

On 09/26/2024 at 10:48 AM, the SPD Educator, also known as the Central Services Educator, stated the following:

- Unless the item would be damaged by going through an ultrasonic machine, this would be a mandatory step according to the standard operating procedures; and
- To his/her knowledge, this step in the process is happening.

On 9/26/2024 at 1:30 PM, these findings were reviewed with hospital leadership.