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Based on review of grievance documentation and interviews with key staff on March 21, 2016, it was determined that the hospital failed to include in the written notice to the patient, the results of the grievance process.

Finding includes:

Southern Maine Health Care Administrative Policy titled "Complaint and Grievance Resolution Policy" stated, "Once the grievance has been thoroughly reviewed, the Risk Management Specialist will send a written response to the patient/representative. The written response will include ....the resolution or planned resolution..."

On March 21, 2016, at approximately 2:15 PM, the documentation of 5 completed grievances was reviewed with the Director of Risk and Safety. The written notice provided to the patients in Complaint A and Complaint C did not include the results of the process used to investigate the grievance.

The Director of Risk and Safety confirmed on March 21, 2016, at approximately 2:30 PM, that the written responses provided to the patients in Complaint A and Complaint C, did not contain the results of the grievance process.

Based on tours of the physical plant which started 3/21/16 and ended on 3/24/15, it was determined that the facility failed to maintain the physical plant in a manner that assures the safety and well-being of the patients. These tours included those conducted with a Southern Maine Health Care (SMHC) Physical Plant tour group, comprised of the Director of Facilities Management, the Safety Manager, the Facility Supervisor, the Director of Environmental Services, and the Risk Management Specialist,

Findings include the following:

1 Medical Center Drive, Biddeford
· High dust was observed in every patient room (including the Intensive Care Unit Dialysis Room, Rooms 401, 402, 417, 419, 420, 423, 427, 428, 434, 435, 436, 438, 304, 308, 310, 316, 318, 323, 326, 327, 330, 334, 344 337, 338, Emergency Department Exam Rooms 1, 6, 8, 10, 11, 12, 14, 15, 16, 17, 20 24, 25, and 26 ) that was visited (observations of some patient rooms was not possible due to the condition of the patient in the room at the time of the tour) in the Hospital. A significant buildup of dust was observed in every room that had lift rail tracks near the ceilings. Dust was also found on the top edge of television screens, on the top surface of clocks, and on the top of the closet doors in many rooms.
· Rusted bottoms of door casings, creating surfaces not easily cleansed or sanitized, were observed in the bathroom doorways in Rooms 417 and 419.
· A buildup of debris was observed along the edges of doorway casings and/or along the thresholds into the bathrooms, and/or around the base of the toilet in the following Rooms: 417, 436, 438, 315, 308, 310, and 316.
· Linen Hamper Carts with rusty casters, creating surfaces not easily cleansed or sanitized, were observed in Ultrasound Room 3, in the Wound Clinic. Additionally a pediatric scale was observed on a cart with rusted casters in Triage Room 2 of the Emergency Department.
· Rusted weights, creating surfaces not easily cleansed or sanitized, were observed in the Orthopedic Storage Room of the Emergency Department.
· Step stools with rusted steps, creating surfaces not easily cleansed or sanitized, were observed in the Fast Track Waiting Room and Exam Room 6 of the Emergency Department.
· A rusted eye-wash station, creating an surface not easily cleansed or sanitized, was observed in the Soiled Utility Room of the Emergency Department.
· Equipment with torn vinyl (or other)coverings, creating surfaces not easily cleansed or sanitized, were observed on the seizure pad in the Clean Utility Room of the Emergency Department , on a stool in Exam Room 10 on a stool, on the handles of a treadmill in the Stress Lab of the Cardiology Area.
· Mayo stands with rusty casters, creating surfaces not easily cleansed or sanitized, were observed in Exam Room 14 and Exam Room 12 of the Emergency Department.
· A reddish-brown, spot that appeared to be dried blood was observed in Room 423 on the wall above the white board.
· Cove bases were observed either missing or pulling away from the wall, creating surfaces not easily cleansed or sanitized in rooms 428 and 436.
· Damaged, broken, cracked or missing flooring, creating surfaces not easily cleansed or sanitized were observed in the Pharmacy of the Mental Health Unit, in Exam Room 11 (separated tiles) and Exam Room 26 missing tile pieces along the wall edge ) of the Emergency Department, in Room 315 (5 holes), and in Ultrasound Room 1 (floor seam separation).
· Items were observed stored on the floor, creating an obstacle to cleaning and/or creating a habitat for mold in the following locations: in the Radiology Storage Room.
· Damaged walls and/or missing paint, creating surfaces not easily cleansed or sanitized were observed in the Fast Track Waiting Room in the corner of the wall by the recliner, in Room 316, above the cove base behind and to the right of the toilet.
· On March 22 & 23, 2016, the pneumatic tube system (PTS) stations located in publicly accessible areas, (hallways), on patient care units MS3 and MS4 were found unsecured. Additionally; the pneumatic tubes stations are not located in an area that is visible and monitored by staff at all times. The PST stations were found to be accessible to anyone passing by the area. The PTS system transports patient supplies, patient records, laboratory specimens, medications and other small items.
· The PTS in the Emergency Department is located in a room off the corridor that was found not able to be secured. Additionally, the pneumatic tube station does not have an enclosure or means to be secured even though it is routinely utilized and accessible to any passerby.
· The main Pharmacy on the Biddeford campus had dusty shelving, and chipped counter tops and exposed plywood edges, which were not easily cleansed or sanitized.
· The pharmacy area located on nursing unit MS3 East had a gouged wall in the entrance area.
· The pharmacy area located on nursing unit MS3 North had a dented and rusted refrigerator that was used to store patient medications. Additionally, the sink area had chipped laminate surface area not easily cleansed or sanitized.
· In the Ambulatory Surgical Unit, bathroom #2 there was a stained ceiling tile.

25 June Street, Sanford
· The two kitchen preparatory sinks in the Kitchen at were not observed to have air gaps in their drains, thus not meeting plumbing code, creating a risk of contamination to foods prepared in those sinks. State of Maine Plumbing Code, Chapter 238, Section 11.C.2.e requires that direct connections between potable water piping and sewer connected wastes shall not exist under any condition, with or without back flow protection.
· Intravenous (IV) poles with rust on the poles and/or on the bases, creating surfaces not easily cleansed or sanitized, were observed in Room 7 (free-standing), Room 6 (on stretcher), Room 4 (on stretcher and free-standing), Room 5 (on stretcher and free-standing), Room 1 (on stretcher and free-standing), Room 12 (free-standing), Room 13 (free-standing), and Room 8 (on stretcher and free-standing) of the Emergency Department.
· Equipment with torn vinyl (or other)coverings, creating surfaces not easily cleansed or sanitized, were observed on the wheel chair arms of a wheel chair stored in the Men's X-Ray Waiting Room, and on an exam table in the Bone Density Room.
· Damaged, broken, cracked or missing flooring, creating surfaces not easily cleansed or sanitized were observed in the second patient bathroom in the main corridor (broken tiles), in the kitchen dish room (broken tiles), and in X-Ray Room 2 (separated seams).
· Damaged walls and/or missing paint, creating surfaces not easily cleansed or sanitized were observed in 25 June Street, Sanford on the window sill in the Stress Test Room, and in the Kitchen on the wall outside the Dish Washing Area.
· The Pharmacy on the Sanford campus had a soiled, discolored floor, dusty shelving, chairs for staff use that were worn with breaks in the surface, that are not easily cleansed or sanitized.
Additionally, a room, within the pharmacy, was noted to be cluttered with approximately 150 used, dusty empty medication bins and old worn, unusable chairs.

2 Livewell Drive, Kennebunk
· Equipment with torn vinyl (or other)coverings, creating surfaces not easily cleansed or sanitized, were observed on the foot rest of the exam table in Room E-5, and on 3 pairs of crutches in a storage room in the South Tower.
· Damaged, broken, cracked or missing flooring, creating surfaces not easily cleansed or sanitized were observed in the Main Corridor Patient Bathroom (separated tiles), in Room C-2 093 (broken tiles), and in Room G-3 (missing tiles).
· Items were observed stored on the floor, creating an obstacle to cleaning and/or creating a habitat for mold in the following locations: in the Housekeeping Closet in the Endoscopy Area.

13 Industrial Park Road, Saco
· A buildup of debris was observed along the edges of doorway casings and/or along the thresholds into the bathrooms, and/or around the base of the toilet in the Patient Bathroom in the Saddleback Pod.
· Equipment with torn vinyl (or other)coverings, creating surfaces not easily cleansed or sanitized, were observed on an exam tables in Exam Room 9 and 2 in the Cadillac Pod.
· Bathroom return vents with significant amounts of dust clinging to them were observed in the Patient Bathroom in the Cadillac Pod.

Other Areas:
· Bathroom return vents with significant amounts of dust clinging to them were observed in both Patient Bathrooms at 12 Thornton Avenue, Saco, and on a crutch located in the Rehabilitation Area of 10 Goodall Drive, Waterboro.
· Items were observed stored on the floor, creating an obstacle to cleaning and/or creating a habitat for mold in the following locations: at 655 Main Street, Saco in the Soiled Utility Room.
· All findings were confirmed at the times of the observations with members of the SMHC Physical Plant tour group.



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Based on observations of the Biddeford campus, surgical suite, and interviews with staff conducted on March 24, 2016, it was determined that not all equipment was being maintained to ensure safety and the quality of its performance.

Findings include:

1. On March 24, 2016, at approximately 10:45 AM, in Operating Room #1, during a surgical procedure, the following was observed:

· The Neoprobe ( a piece of intraoperative diagnostic equipment used in surgical procedures) had tape on the right side of the machine covering a cracked area and the inspection sticker expired on October 2015;

· The eye surgeon chair had tape covering a cracked area on the right side arm;

· The Force FX Electrosurgical generator had rusty castors;

· The suction machine had rusty castors;

· The large back surgical table had rust on all 4 legs; and

· A kick bucket was noted to have rusty castors.

The above findings were indicative of surfaces that are not easily cleansed or sanitized and were confirmed, on March 24, 2016, by the Circulating Nurse, in Operating Room #1, during the surgical procedure.


2. On March 24, 2016, at approximately 12:00 PM, the following was observed in the surgical suite:

· A mini C arm (a fluoroscopic imaging scanner which has the shape of a " C " and is used in surgical procedures to provide real time x-ray type of digital imaging)was observed to not have a sticker indicating it had been checked for safety;

· A slave monitor ( a secondary video monitor used to visualize images from remote scopes used in surgical procedures) in the endoscopy suite was found to have dust on the upper portions of the monitor; this created a risk for contamination and infections should the dust fall or get blown from air circulation onto sterile fields below the monitor. Additionally, this monitor lacked inspection sticker to indicate that it had been checked for safety..

These findings were confirmed at the time of the observations, by the Surgical Nurse Manager.


3. On March 24, 2016, at approximately 12:30 PM, the following was observed in Operating Room #3:

· The GYN Tower had rusty castors; and

· A ring stand (a rolling stand that has a stainless steel ring opening which can be used for holding large basins) had rusty castors.

These findings were indicative of surfaces that are not easily cleansed or sanitized and were confirmed at the time of the observations, by the Surgical Nurse Manager.