HospitalInspections.org

Based on observations and interviews with key personnel on June 20 - 22, 2016, it was determined that the facility failed to provide a preventive maintenance program to insure that all essential mechanical, electrical, and patient care equipment were maintained in a safe operating condition.

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.

1. On June 20, 2016, at approximatley11:00 AM, the food preparatory sink in the Kitchen of Blue Hill Memorial Hospital was observed not to have an air gap installed in its drain line, providing a direct connection to the waste water system and providing a potential risk for contamination of the food provided to patients. This finding was confirmed at the time of the observation with the Food Service Director.

2. On June 20, 2016, from 11:00 AM to 3:30 PM during a tour of Blue Hill Memorial Hospital with the Environmental Services Assistant Supervisor (ESAS), the following was observed:
· Missing paint, creating uncleanable surfaces, on the wall behind a chair and by the wall hung hand sanitizer, in the Emergency Department Waiting Room.
· Worn vinyl, creating an uncleanable surface, on the exam table leg stirrups, in Room 5 of the Emergency Department.
· The pull cord for the call light ending three feet from the floor, out of reach of anyone who may have fallen to the floor, in the Emergency Department Public/Patient Restroom
· Rusty casters, creating uncleanable surfaces, on an intravenous pole in the Nuclear Medicine Room.
· A rip in the seat of a chair, covered over with tape that was peeling off, creating an uncleanable surface, in the Ultrasound Room.
· The pull cord for the call light wrapped around the grab bar, in the Radiology Restroom, rendering the call light inoperable by use of the pull cord.
· Rusty casters, creating uncleanable surfaces, on an intravenous pole in Room 1 of the Special Care Unit.
· A rough textured surface on a wall-mounted wooden base, creating an uncleanable surface, in the Post-Anesthesia Care Unit.
· The pull cords for the call lights wrapped around the grab bars in both Restrooms in the Ambulatory Surgical Unit, rendering the call lights inoperable by use of the pull cord.
· The pull cord for the call light wrapped around the grab bar, in the Restroom of Room 10 of the Medical/Surgical Unit, rendering the call light inoperable by use of the pull cord.
These findings were confirmed at the time of the observations with the ESAS.

3. On June 21, 2016, from 8:50 AM to 9:20 AM, during a tour of Island Family Medicine with the Maintenance Worker (MW), the following was observed:
· Cracked floor tiles, being covered by duct tape, creating an uncleanable surface, in Room 6.
· Torn vinyl in the left corner of the foot end of the exam table, creating an uncleanable surface, in Room 3.
These findings were confirmed at the time of the observations with the MW.

4. On June 21, 2016, from 9:45 AM to 10:45 AM, during a tour of Castine Community Health with the Maintenance Worker (MW), the following was observed:
· An ophthalmoscope (a device used to exam the interior of the eye) and otoscope (a device used to examine the ears), had a sticker indicating the equipment was due to be inspected October 15, 2015, for medical safety, in room 2.
· A baby scale without a sticker to indicate it had been checked for patient safety in Room 2.
· An exam table had a sticker indicating the equipment was due to be inspected October 15, 2015, for medical safety, in room 2.
These findings were confirmed at the time of the observations with the MW.

5. On June 21, 2016, from 11:15 AM to 12:30 PM, during a tour of the first floor of Sussman Medical Office Building with the Maintenance Worker (MW), the following was observed:
· Veneer missing from the end of the sink splash guard on the side next to the far wall, creating an uncleanable surface, in the Restroom.
· A loose floor tile in the left corner of the Restroom, behind the toilet, creating an uncleanable surface, in Room 3 of the Specialty Clinic.
· The pull cord for the call light wrapped around the grab bar in the Restroom of Room 3 in the Specialty Clinic, rendering the call light inoperable by use of the pull cord.
· An exam lamp had a sticker which indicated the equipment was due February, 2016 for a medical safety inspection, in Room 2 of the Specialty Clinic.
· An exam lamp without a sticker to indicate it had been checked for patient safety in Room 3 of the Specialty Clinic
· Welsh-Allen thermometer without a sticker to indicate it had been checked for patient safety in Room 3 of the Specialty Clinic
· Broken and worn corners on five anti-fatigue mats, creating uncleanable surfaces, in the Laboratory. Replacement mats were ordered by the facility on June 21, 2016.
· Seven cracked floor tiles in the X-Ray Room creating uncleanable surfaces.
· The pull cord for the call light tied up just under the switch and unreachable from the floor in the Restroom of Women ' s Health.
· The pull cord for the call light tied up just under the switch and unreachable from the floor in the Restroom of Radiology.
These findings were confirmed at the time of the observations with the MW.

6. On June 22, 2016, from 7:30 AM to 9:00 AM, during a tour of the Bucksport Outpatient Urology Office and the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office with the Office Managers (OM), the following was observed:
· The exit sign by Main Entrance of the Bucksport Outpatient Urology Office does not light when button is pushed.
· The exit sign by door to stairs of the Bucksport Outpatient Urology Office goes very dim when button is pushed.
· The exit sign in corridor by the door in the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office does not work.
· In Room 4, the Hi-Low table, in the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office, has a damaged, non-intact surface that is patched with tape and unable to be properly sanitized
· In the Speech Office in the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office, there are two (2) patient chairs with fabric upholstery that are unable to be properly sanitized.
· In the Exercise Gym Room in the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office, a small Hi-Low table has a damaged, non-intact surface that is taped and not able to be properly sanitized.
· In the Exercise Gym Room in the Bucksport Physical Therapy/Occupational Therapy Rehabilitation Office, the Parallel bars have worn wooden surface that cannot be properly sanitized.
These findings were confirmed at the time of the observations with the OM.

7. On June 22, 2016, from 9:30 AM to 9:45 AM, during a tour of the Cardiopulmonary Office in Blue Hill Memorial Hospital with the Office Managers (OM), the following was observed:
· 3 chairs with fabric upholstery, in the Cardiopulmonary Office are not able to be properly sanitized. Two of these chairs have wooden arms with worn, non-intact surfaces that are not able to be properly sanitized.
· The Oxygen and Diffusion Gas bottles, in the Respiratory Therapy Office of the hospital are standing against wall and are being held loosely in place by a small chain that is hooked to the plaster wall that likely would not be able to support the weight of either of the gas bottles if they fell.
These findings were confirmed at the time of the observations with the OM.


8. On June 22, 2016, at approximately 10:00 AM, in an interview with the Director of the Physical Plant it was determined that:
· There is currently no complete equipment inventory, thus an effective preventive maintenance program is not possible.
· There is no record of monitoring of air exchanges in the Operating Rooms.

9. On June 22, 2016, from 10:00 AM to 11:00 AM, during a tour of the second floor of Sussman Medical Office Building with the Maintenance Worker (MW), the following was observed:
· The Pod A patient bathroom door, " second bathroom " door, and examination Room 2 door were delaminated and had areas where the paint was worn off, creating uncleanable surfaces.
· The Pod B patient bathroom door and examination Room 10 door were delaminated and had areas where the paint was worn off, creating uncleanable surfaces.

These findings were confirmed with the MW at the time of the observations.


10. On June 22, 2016, from 10:30 AM to 11:00 AM, during a tour of the Outpatient Women ' s Health Office in Blue Hill Memorial Hospital with the Practice Manager (PM), the following was observed:
· Two 3.5 millimeter Biopsy Punches were outdated (Expiration July, 2014).
· One 15 cubic centimeter bottle of Trichlorocetic Acid had been opened without a label of the date opened.
· Two 4 millimeter Biopsy Punches were outdated (Expiration November, 2015).
· One 5 millimeter Biopsy Punch was outdated (Expiration August, 2015).
These findings were confirmed at the time of the findings with the PM.

On June 22, 2016, from 11:00 AM to 1:00 PM, on a tour of Blue Hill Memorial Hospital with the Vice President of Clinical and Support Services (VPCSS), the following was observed:
· Damage to the wall by the bathroom door in the Chemotherapy Room of the Oncology Outpatient Unit creating an uncleanable surface.
· Three wooden chairs with worn surfaces in the Family Room/Lounge of the Oncology Outpatient Unit that cannot be properly sanitized.
· The sink back splash is unsealed in Room 10 of the Medical/Surgical Unit, creating an uncleanable surface.
· The chair rail by the door is worn and chipped in Room 10 of the Medical/Surgical Unit and is unable to be properly sanitized.
· The wallpaper in Room 10 of the Medical/Surgical Unit has raised, loose seams, creating an uncleanable surface.
· Blistered paint on the lower wall by the toilet in Room 14 of the Medical/Surgical Unit, creating an uncleanable surface.
· Wooden furniture with worn, non-intact surfaces in Room 14 of the Medical/Surgical Unit, that is unable to be properly sanitized.
· A door that is chipped and scratched in Room 14 of the Medical/Surgical Unit, and is unable to be properly sanitized.
These findings were confirmed at the time of the observations with the VPCSS.

Based on a tour of the facility on June 20 - 21, 2016, it was determined that the facility failed to keep the premises clean and orderly.

1. On June 20, 2016 from approximately 11:00 AM to approximatley3:30 PM, during a tour of Blue Hill Memorial Hospital with the Environmental Services Assistant Supervisor (ESAS), significant dust (enough dust to completely coat a finger-tip if it wiped across approximately 5 inches of the surface) was observed on:
· The blades of a wall mounted fan in the Ultrasound Room of the hospital.
· On the top surface, near the wall, of the wall mounted lights in the Ambulatory Surgical Unit in Pre-Operative Rooms 1, 2, 3, and 4 of the hospital.
· On the top surface of the paper towel holder in the Post-Anesthesia Care Unit of the hospital.

These findings were confirmed at the time of the observations with the ESAS.

2. On June 20, 2016 at approximately 2:45 PM, the floor in the Computerized Tomography (CT) Room was observed to be very sticky near the head of the CT table. This finding was confirmed with the Environmental Services Assistant Director (ESAD) who stated, at that time, that the floor is cleaned in the mornings, Later that day the ESAD stated that the staff should have communicated that contrast had been spilled, so that it could have been addressed. The ESAD stated at approximately 4:00 PM that the floor had been cleaned.

3. On June 21, 2016 from 9:45 AM to 10:45 AM, during a tour of Castine Community Health with the Maintenance Worker (MW), a cardboard box of urine sample cups was observed stored under a sink in the Laboratory, creating a potential habitat for microorganisms to grow.
This finding was confirmed at the time of the observation with the MW.
4. On June 21, 2016 from 11:15 AM to 12:30 PM, during a tour of the first floor of Sussman Medical Office Building with the Maintenance Worker (MW), multiple cardboard boxes containing spare parts, and 2 blood boxes were observed stored on the floor in the Laboratory, resulting in the inability to properly clean the floor and creating the potential to absorb moisture in the containers, creating a habitat for microorganisms to grow. The facility reports all boxes were moved onto pallets on June 21, 2016.

This finding was confirmed at the time of the observation with the MW.
5. On June 22, 2016 from 10:00 AM - 11:00 AM, on a tour of the second floor of the Sussman Building with the Maintenance Worker (MW), multiple cardboard boxes were observed stored on the floor in the Pod A Housekeeping Closet and in the Pod B Linen Closet, four (4) large bags of urine specimen cups and three (3) cardboard boxes of clean speculums (used in vaginal examinations) were observed stored on the floor, resulting in the inability to properly clean the floor and creating the potential to absorb moisture in the containers, creating a habitat for microorganisms to grow.

These findings were confirmed at the time of the observations with the MW.
6. On June 22, 2016, from 11:00 AM to 1:00 PM, on a tour of Blue Hill Memorial with the Vice President of Clinical and Support Services (VPCSS), it was observed that the Chemotherapy Restroom Threshold is loose and collecting a dark colored material.
This finding was confirmed at the time of the finding with the VPCSS.

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 June 23, 2016, for the Maine State Fire Marshal ' s Office Life Safety Code survey.

Based on interviews and observations with the Director of Pharmacy on June 21, 2016, between 10 AM and 3 PM, it was determined that the pharmacy failed to following accepted standards of practice related to United States Pharmacopeia (USP 797).

Finding includes:

1. The Director of Pharmacy stated at approximately 10 AM, on June 21, 2016, that the pharmacy would give compounded sterile products (CSPs) up to 24 hours beyond use dating when prepared in a laminar flow hood.

2. Direct observation revealed that the facilities certified laminar flow hood was contained in a segregated compounding area (not a certified clean room). USP 797 designates that under the above circumstances the CSP must have a beyond use date of 12 hours or less.

3. The Pharmacy Department contracted with an external pharmacy to prepare all Oncology compounded sterile products (CSPs). During interviews and telephone conversations with the Director of Pharmacy of Blue Hill Hospital and the contracted external pharmacy staff, they were unable to supply sufficient evidence to validate that the contracted pharmacy was in compliance with USP 797. Additionally, the contracted pharmacy could not provide policies and procedures for maintaining cleaning processes and staff training per USP 797.

Based on observation and interviews with key personnel conducted on June 21, 2016, it was determined that the facility failed to provide safeguards against the unauthorized use of medical record information.

Finding includes:
1. During a site visit to the Outpatient Urology Office in Bucksport Maine, conducted on June 21, 2016, at approximately 7:50 AM, the medical records room, located in an unsupervised hallway, was observed to be unlocked and readily accessible by persons that are not authorized access to the medical record information. It was observed that this hallway was readily accessible through an unobserved, unlocked door adjacent to the main entrance.
This finding was immediately confirmed by the Office Manager who stated, "Yes, we leave that door (Medical Records room door) unlocked during the day so we can just come in without unlocking it."
2. During a site visit to the Outpatient Orthopedic Office, located on the Blue Hill Memorial Hospital Campus, June 21, 2016, at approximately 11:10 AM, it was observed that patient medical records that are stored on open shelves behind the reception desk, were readily accessible to housekeeping personnel who clean the office when office staff is not present.
This finding was immediately confirmed by the Office Manager, who stated, "No one else is in the office when the cleaners are here."