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Based on observations and interviews with key personnel on November 27-30, 2016, it was determined that the facility failed to provide preventive maintenance programs, and periodic monitoring to insure all essential mechanical, electrical, and patient care equipment was maintained in a safe operating condition.

Finding includes:

During a tour of the Medical-Surgical Unit (MSU) on November 28, 2016, at approximately 10:39 AM, it was observed that the periodic inspection logs for the code carts [portable carts containing necessary equipment used in a medical emergency to resuscitate a patient] failed to document that the carts were inspected on a daily basis as required by hospital policy.

· It was noted during review of the inspection of the logs, that the logs failed to contain evidence that an equipment check was conducted on the following dates for the pediatric cart: October 15, 2014, February 26, 2015, April 16, 2015, June 19, 2015, October 26, 2015, December 6, 2015 and January 4, 2016. The adult cart had inspection checks missing on the following dates: July 12, 2014 and June 11, 2015.

· Hospital policy titled "Locations and Care of Crash Carts and Defibrillators" states: "3. All crash carts are kept locked. The lock is routinely checked for integrity; the logbook is signed. * In all 24°[hour] Nursing areas, lock and defibrillator functions checks are done each shift."

· This finding was confirmed by the MSU Nurse Manager and the Associate Chief Operating Officer on November 28, 2016, at approximately 10:40 AM.



33759

Based on observations and interviews with key personnel, it was determined that the facility failed to ensure that the facilities, supplies, and equipment were maintained at an acceptable level of safety and quality.
Finding includes:
On November 28, 2016, during a tour of outpatient facilities with the Environmental Services Director and Director of Facilities the following observations were made:
· In Exam Room 2 in the Lincolnville Regional Health Center at 2399 Atlantic Highway, Lincolnville, Maine, rusty casters on an over-the-bed table were observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally torn vinyl was observed on the corner of the vinyl cover of the exam table creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 3 of the Donald S. Walker Health Center at 43 West Main Street, Liberty, Maine, a hole in the vinyl covering of the chair was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Health Connections at 163 Northport Avenue, Belfast, Maine, torn vinyl on the edge of an exam table was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 1 and in the Laboratory of Internal Medicine in the Cobb Medical Office Building at 16 Fahey Street, Belfast, Maine, a black, sticky, glue like substance oozing up between the tiles was observed. In the restroom, unsealed spaces between the floor tiles were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 2 of Belfast Neurology Associates, Suite 102, in the Cobb Office Building, a black, sticky, glue like substance oozing up between the tiles was observed, creating uncleanable surfaces that cannot be easily sanitized.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.



On November 29, 2016, during a tour of outpatient facilities and the hospital with the Environmental Services Director and Director of Facilities the following observations were made:
· In the Hallway of the Cobb Medical Office Building, 13 cracked tiles over an expansion joint were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Family Medicine, Suite 202, in the Cobb Medical Office Building, many tears in the vinyl covering the seat and back of a wheelchair were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the Infusion Therapy Area in the Cobb Medical Office Building, there was no functional air gap observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In Exam Room 1 in Surgical Services, Suite 201 in the Cobb Medical Office Building, rust build-up on the floor near the exam table was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Cardiac Rehabilitation, Suite 213 in the Ludwig Medical Office Building, unsealed gaps in the floor tiles in front of the toilet in the restroom were observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally, torn vinyl on the covering of the footboard of the tilt table was observed, creating an uncleanable surface that cannot be easily sanitized.
· In Exam Room 1 in Orthopedics, Suite 214 of the Ludwig Medical Office Building, dust on top of the closet was observed, indicating an uncleaned and unsanitized surface.
· In Echo Lab 2 of the Ludwig Medical Office Building, dust on top of the closet was observed, indicating an uncleaned and unsanitized surface.
· In Oncology, Suite 2017 in the Ludwig Medical Office Building, there was no functional air gap observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the hospital Laboratory, the call light pull cord was observed tied up, making it too short to be reached from the floor, disabling the function of the call light. Additionally, the antifatigue floor mat was observed to be cracked and/or broken around all edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Family Practice, Suite 112, in the Ludwig Medical Office Building, residue build-up near the base of the exam table was observed, indicating an uncleaned and unsanitized surface.
· In the Consult Room of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a lamp was observed with no safety sticker, indicating it had not been inspected for electrical safety.
· In the Gym of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a cycle ergometer with cracked hand grips was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 2 of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, 2 puncture holes in the vinyl covering of the exam table were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 9 of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a black, sticky, glue like substance oozing up between the tiles was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 223 in the Medical Surgical Unit (MSU), a significant accumulation of dust on top of the closet was observed, indicating an uncleaned and unsanitized surface. Additionally, the call light cord was observed to be tied up and too short to be reached from the floor, disabling the function of the call light.
· In Room 221 in the MSU, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light. Additionally, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed, indicating an uncleaned and unsanitized surface.
· In Room 220 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top edge of the white board, indicating an uncleaned and unsanitized surface. Additionally the bedside table was delaminating on the edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 225 in the MSU, a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface. The call light cord was too short to be reached from the floor, disabling the function of the call light. There was damage into the wallboard of the walls behind the recliner and behind the other chair in the room, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 226 in the MSU a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 219 in the MSU the bedside table was delaminating on the edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 227 in the MSU a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In the MSU Kitchenette, no functional air gap was observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the MSU Oxygen Storage Room, a Kangaroo Pump with a Synernet sticker indicating it was due for inspection in August of 2015, potentially creating an opportunity for a malfunctions pump to be placed in service for patient care.
· In Room 215 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 211 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 210 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, on the top of the closet, and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 209 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In Room 207 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In Room 206 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In the Swing Bed Rehabilitation Room, a pair of crutches with cracked arm pads was observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally, the call light cord was observed to be too long and wrapped around the grab bar, disabling the function of the call light.
· In the Intensive Care Unit (ICU), 2 desk lamps were observed with no safety stickers present indicating they had not been checked for electrical safety, creating a possible fire hazard.
· In Room C in the ICU, a significant accumulation of dust was observed on the top of the closet, indicating an uncleaned and unsanitized surface.
· In Room B in the ICU, a significant accumulation of dust was observed on the top of the ceiling mounted lift, indicating an uncleaned and unsanitized surface.
· In the ICU Clean Utility Room, a surgical clipper was observed with no safety sticker present indicating it had not been checked for electrical safety, creating a possible hazard to patients.
· In Room 1 of the Emergency Department (ED), a significant accumulation of dust was observed on the top of the support arm of the over-the-bed light, indicating an uncleaned and unsanitized surface.
· In Room 2 of the ED, a call light string that was made of an absorbent material was observed, creating an uncleanable surface that cannot be easily sanitized.
· In Bay 5 of the ED, a significant accumulation of dust was observed on the top of the support arm of the over-the-bed light, indicating an uncleaned and unsanitized surface.
· The ED ice machine was observed to have no functional air gap in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the Mammography Bathroom, a tear in the vinyl covering the back of the chair, was observed creating an uncleanable surface that cannot be easily sanitized.
· In Ultrasound Room 1, 2 tears in the vinyl covering the exam table were observed, creating an uncleanable surface that cannot be easily sanitized.
· In the Bone Density Room, a black, sticky, glue like substance oozing up between the tiles, was observed, creating uncleanable surfaces that cannot be easily sanitized.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.
On November 30, 2016 during a tour of the hospital with the Environmental Services Director and Director of Facilities the following observations were made:
· In the Central Sterilization area, a rusted base on a nitrous oxide tank cart was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the Treatment Room in the Women, Infants, and Children Unit, 2 lamps were observed with no safety stickers present indicating they had not been checked for electrical safety, creating a possible fire hazard. Additionally, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light.
· In Room 106 in the Women, Infants, and Children Unit, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light.
· In Birthing Room 1 in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top edge of the bathroom mirror, on the top of the light over the baby warmer, and on the wall molding behind the bed, indicating an uncleaned and unsanitized surface.
· In Birthing Room 2 in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top edge of the white board and on the wall molding behind the bed. Additionally there was a lamp was observed with no safety sticker present indicating it had not been checked for electrical safety, creating a possible fire hazard.
· In the Women, Infants, and Children Unit an ice machine was observed with no functional air gap in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the Nursery in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top of the light over the baby warmer, indicating an uncleaned and unsanitized surface.
· In Room 225 of MSU, damage to the inside edge of the door was observed, creating an uncleanable surface that cannot be easily sanitized.
· In the MSU Storage Room, a door with many scratches and gouges was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the MSU, gouges in the hand rails on the cart side of the hall between rooms 206 and 211 and between the stairs and room 227 were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Central Stores, a significant layer of dust and dirt was observed on the shelves holding patient supplies, creating a potential of contamination of these supplies, indicating an uncleaned and unsanitized surface.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.

Based on observations and interviews with key personnel on November 30, 2016, it was determined that the facility failed to ensure proper storage of trash.
The 2013 Maine Food Code states in 5-501.14 (A): " Receptacles and waste handling units for Refuse, recyclables, and returnables used with materials containing Food residue and used outside the Food or Eating Establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. "
Finding includes:
· On a tour of the of the hospital waste holding area on November 30, 2016, 2 of 4 dumpsters were observed with 1/3 to ½ of the lids broken off and missing. This observation was confirmed at the time of the observation with the Kitchen Manager.

Based on record reviews and interviews with key personnel on November 30, 2016, it was determined that the facility failed to ensure that temperature and air-flow were maintained at acceptable standards in the Operating Rooms.
Finding includes:
· The facility Surgical Suite Infection Control Policy states in 1. B. " Air changes in the operating room provide at least 20-25 air exchanges per hour and 5 outside air changes per hour. " and in 1. c. it states, " ...Recommended temperature is between 68-73 degrees Fahrenheit ....Cases will not be done until temperature and humidity are within approved limits unless the surgeon determines necessity. "
· On November 30, 2016, at 10:50 AM, in an interview with the HVAC (Heating Ventilation Air Conditioning) Team Leader, he stated that their system is not currently set up to tell them how many air changes are being completed per hour in the operating rooms.
· During a review of the Operating Room (OR) temperature and humidity records for the past 6 months, many of the hourly readings were below the facility ' s standards for operating room temperatures.
· A review of the OR case records for the previous 6 months did not indicate that any cases had been delayed due to OR temperatures being out of range nor were there any notes stating that OR temperatures were out of range at the start of cases.
· In an interview with the OR Manager on November 30, 2016, at 2:50 PM, she stated that they do not document starting cases if the temperature is out of range and have no documentation that they adjust temperatures if they are found to be out of range.

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 Novvember 28, 2016, for the Maine State Fire Marshal ' s Office Life Safety Code survey.

Based on document review and interview with key personnel on November 30, 2016, it was determined that the facility failed to maintain evidence of a properly executed informed consent form.

Finding includes:

A review of 15 inpatient medical records was conducted on November 30, 2016. 1 of 15 medical records (Record LL), failed to contain a scanned copy of the consent form signed by the patient.

The file contained a scanned copy of "page 1" of the form titled "Consent to Treat", which contained a scan of only the first page of the form, and did not contain a scan of the second page, (where the signature of the individual providing consent would be located).

Additionally, the image of the first page showed the identified patient's name on the upper right corner of the page. The form contained the name of another individual, and a checkbox was both checked and circled identifying that other individual as "myself" (indicating that that individual was the patient).

This was confirmed by the Director of Patient Registration on November 30, 2016, at approximately 2:06 PM, who also stated that she was unable to locate the original paper copy of the consent.

Based on record review and interviews with key personnel on November 28, 2016, it was determined that the facility failed to inform a swing bed patient of their swing bed patient rights prior to providing care in 1 of 5 records reviewed (Record A).
Finding includes:
During the review of Record A, conducted on November 28, 2016 , it was determined that the record of the swing bed patient admitted to swing status on November 25, 2016, failed to contain any documentation that the patient had been informed of the swing bed patient rights.
This was confirmed on November 28, 2016, at 11:00 AM by the Swing Bed Coordinator.
On November 29, 2016, at approximately 9:00 AM, the Swing Bed Coordinator informed the surveyor that the patient has since been informed of their swing bed patient rights.

Based on record review and interviews with key personnel on November 29, 2016, it was determined that the facility failed to ensure that the discharging physician completed the required discharge summary per the hospital policy in 1 of 5 swing bed records reviewed (Record C).
The Discharge Summary- Swing Bed Policy states " The discharge summary will be completed within 7 days of discharge. "
Finding includes:
On November 29, 2016, during review of Record C, it was determined that the patient was discharged from the swing bed program on November 15, 2016 (record review was conducted 14 days after discharge). The record failed to contain the required discharge summary .
This finding was confirmed on November 29, 2016, at 10:00 AM by the Director of Quality and Safety.
On November 30, 2016, at approximately 9:00 AM, the Director of Quality and Safety presented the discharge summary for Record C. It was dated November 29, 2016 at 1:59 PM.

Based on document review and interviews with key personnel on November 29-30, 2016, it was determined that the facility failed to inform patients (or their support person) of their visitation rights.

Finding includes:

A review of 15 inpatient medical records was conducted November 29-30, 2016. All 15 medical records failed to contain documentation that the patient (or support person) received notice of their visitation rights (Records X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, and LL).

This finding was confirmed with the unit nurse at the time of chart review, and was also confirmed during an interview with the Chief Nursing Officer on November 30, 2016, at approximately 2:00 PM.

Based on observations and interviews with key personnel on November 27-30, 2016, it was determined that the facility failed to provide preventive maintenance programs, and periodic monitoring to insure all essential mechanical, electrical, and patient care equipment was maintained in a safe operating condition.

Finding includes:

During a tour of the Medical-Surgical Unit (MSU) on November 28, 2016, at approximately 10:39 AM, it was observed that the periodic inspection logs for the code carts [portable carts containing necessary equipment used in a medical emergency to resuscitate a patient] failed to document that the carts were inspected on a daily basis as required by hospital policy.

· It was noted during review of the inspection of the logs, that the logs failed to contain evidence that an equipment check was conducted on the following dates for the pediatric cart: October 15, 2014, February 26, 2015, April 16, 2015, June 19, 2015, October 26, 2015, December 6, 2015 and January 4, 2016. The adult cart had inspection checks missing on the following dates: July 12, 2014 and June 11, 2015.

· Hospital policy titled "Locations and Care of Crash Carts and Defibrillators" states: "3. All crash carts are kept locked. The lock is routinely checked for integrity; the logbook is signed. * In all 24°[hour] Nursing areas, lock and defibrillator functions checks are done each shift."

· This finding was confirmed by the MSU Nurse Manager and the Associate Chief Operating Officer on November 28, 2016, at approximately 10:40 AM.



33759

Based on observations and interviews with key personnel, it was determined that the facility failed to ensure that the facilities, supplies, and equipment were maintained at an acceptable level of safety and quality.
Finding includes:
On November 28, 2016, during a tour of outpatient facilities with the Environmental Services Director and Director of Facilities the following observations were made:
· In Exam Room 2 in the Lincolnville Regional Health Center at 2399 Atlantic Highway, Lincolnville, Maine, rusty casters on an over-the-bed table were observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally torn vinyl was observed on the corner of the vinyl cover of the exam table creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 3 of the Donald S. Walker Health Center at 43 West Main Street, Liberty, Maine, a hole in the vinyl covering of the chair was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Health Connections at 163 Northport Avenue, Belfast, Maine, torn vinyl on the edge of an exam table was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 1 and in the Laboratory of Internal Medicine in the Cobb Medical Office Building at 16 Fahey Street, Belfast, Maine, a black, sticky, glue like substance oozing up between the tiles was observed. In the restroom, unsealed spaces between the floor tiles were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 2 of Belfast Neurology Associates, Suite 102, in the Cobb Office Building, a black, sticky, glue like substance oozing up between the tiles was observed, creating uncleanable surfaces that cannot be easily sanitized.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.



On November 29, 2016, during a tour of outpatient facilities and the hospital with the Environmental Services Director and Director of Facilities the following observations were made:
· In the Hallway of the Cobb Medical Office Building, 13 cracked tiles over an expansion joint were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Family Medicine, Suite 202, in the Cobb Medical Office Building, many tears in the vinyl covering the seat and back of a wheelchair were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the Infusion Therapy Area in the Cobb Medical Office Building, there was no functional air gap observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In Exam Room 1 in Surgical Services, Suite 201 in the Cobb Medical Office Building, rust build-up on the floor near the exam table was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Cardiac Rehabilitation, Suite 213 in the Ludwig Medical Office Building, unsealed gaps in the floor tiles in front of the toilet in the restroom were observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally, torn vinyl on the covering of the footboard of the tilt table was observed, creating an uncleanable surface that cannot be easily sanitized.
· In Exam Room 1 in Orthopedics, Suite 214 of the Ludwig Medical Office Building, dust on top of the closet was observed, indicating an uncleaned and unsanitized surface.
· In Echo Lab 2 of the Ludwig Medical Office Building, dust on top of the closet was observed, indicating an uncleaned and unsanitized surface.
· In Oncology, Suite 2017 in the Ludwig Medical Office Building, there was no functional air gap observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the hospital Laboratory, the call light pull cord was observed tied up, making it too short to be reached from the floor, disabling the function of the call light. Additionally, the antifatigue floor mat was observed to be cracked and/or broken around all edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Family Practice, Suite 112, in the Ludwig Medical Office Building, residue build-up near the base of the exam table was observed, indicating an uncleaned and unsanitized surface.
· In the Consult Room of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a lamp was observed with no safety sticker, indicating it had not been inspected for electrical safety.
· In the Gym of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a cycle ergometer with cracked hand grips was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 2 of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, 2 puncture holes in the vinyl covering of the exam table were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Exam Room 9 of the Occupational Therapy/Physical Therapy, Suite 107, in the Ludwig Medical Office Building, a black, sticky, glue like substance oozing up between the tiles was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 223 in the Medical Surgical Unit (MSU), a significant accumulation of dust on top of the closet was observed, indicating an uncleaned and unsanitized surface. Additionally, the call light cord was observed to be tied up and too short to be reached from the floor, disabling the function of the call light.
· In Room 221 in the MSU, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light. Additionally, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed, indicating an uncleaned and unsanitized surface.
· In Room 220 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top edge of the white board, indicating an uncleaned and unsanitized surface. Additionally the bedside table was delaminating on the edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 225 in the MSU, a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface. The call light cord was too short to be reached from the floor, disabling the function of the call light. There was damage into the wallboard of the walls behind the recliner and behind the other chair in the room, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 226 in the MSU a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 219 in the MSU the bedside table was delaminating on the edges, creating uncleanable surfaces that cannot be easily sanitized.
· In Room 227 in the MSU a significant accumulation of dust was observed on the top of the closet and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In the MSU Kitchenette, no functional air gap was observed in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the MSU Oxygen Storage Room, a Kangaroo Pump with a Synernet sticker indicating it was due for inspection in August of 2015, potentially creating an opportunity for a malfunctions pump to be placed in service for patient care.
· In Room 215 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 211 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 210 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, on the top of the closet, and on the top edge of the white board, indicating an uncleaned and unsanitized surface.
· In Room 209 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In Room 207 in the MSU, a significant accumulation of dust was observed on the top of the wall-mounted light fixture over the bed and on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In Room 206 in the MSU, a significant accumulation of dust was observed on the top of the bathroom mirror, indicating an uncleaned and unsanitized surface.
· In the Swing Bed Rehabilitation Room, a pair of crutches with cracked arm pads was observed, creating uncleanable surfaces that cannot be easily sanitized. Additionally, the call light cord was observed to be too long and wrapped around the grab bar, disabling the function of the call light.
· In the Intensive Care Unit (ICU), 2 desk lamps were observed with no safety stickers present indicating they had not been checked for electrical safety, creating a possible fire hazard.
· In Room C in the ICU, a significant accumulation of dust was observed on the top of the closet, indicating an uncleaned and unsanitized surface.
· In Room B in the ICU, a significant accumulation of dust was observed on the top of the ceiling mounted lift, indicating an uncleaned and unsanitized surface.
· In the ICU Clean Utility Room, a surgical clipper was observed with no safety sticker present indicating it had not been checked for electrical safety, creating a possible hazard to patients.
· In Room 1 of the Emergency Department (ED), a significant accumulation of dust was observed on the top of the support arm of the over-the-bed light, indicating an uncleaned and unsanitized surface.
· In Room 2 of the ED, a call light string that was made of an absorbent material was observed, creating an uncleanable surface that cannot be easily sanitized.
· In Bay 5 of the ED, a significant accumulation of dust was observed on the top of the support arm of the over-the-bed light, indicating an uncleaned and unsanitized surface.
· The ED ice machine was observed to have no functional air gap in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the Mammography Bathroom, a tear in the vinyl covering the back of the chair, was observed creating an uncleanable surface that cannot be easily sanitized.
· In Ultrasound Room 1, 2 tears in the vinyl covering the exam table were observed, creating an uncleanable surface that cannot be easily sanitized.
· In the Bone Density Room, a black, sticky, glue like substance oozing up between the tiles, was observed, creating uncleanable surfaces that cannot be easily sanitized.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.
On November 30, 2016 during a tour of the hospital with the Environmental Services Director and Director of Facilities the following observations were made:
· In the Central Sterilization area, a rusted base on a nitrous oxide tank cart was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the Treatment Room in the Women, Infants, and Children Unit, 2 lamps were observed with no safety stickers present indicating they had not been checked for electrical safety, creating a possible fire hazard. Additionally, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light.
· In Room 106 in the Women, Infants, and Children Unit, the call light cord was observed to be too short to be reached from the floor, disabling the function of the call light.
· In Birthing Room 1 in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top edge of the bathroom mirror, on the top of the light over the baby warmer, and on the wall molding behind the bed, indicating an uncleaned and unsanitized surface.
· In Birthing Room 2 in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top edge of the white board and on the wall molding behind the bed. Additionally there was a lamp was observed with no safety sticker present indicating it had not been checked for electrical safety, creating a possible fire hazard.
· In the Women, Infants, and Children Unit an ice machine was observed with no functional air gap in the plumbing connecting the drain to the wastewater system, creating an opportunity for wastewater to back-up into the potable water system. 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.
· In the Nursery in the Women, Infants, and Children Unit, a significant accumulation of dust was observed on the top of the light over the baby warmer, indicating an uncleaned and unsanitized surface.
· In Room 225 of MSU, damage to the inside edge of the door was observed, creating an uncleanable surface that cannot be easily sanitized.
· In the MSU Storage Room, a door with many scratches and gouges was observed, creating uncleanable surfaces that cannot be easily sanitized.
· In the MSU, gouges in the hand rails on the cart side of the hall between rooms 206 and 211 and between the stairs and room 227 were observed, creating uncleanable surfaces that cannot be easily sanitized.
· In Central Stores, a significant layer of dust and dirt was observed on the shelves holding patient supplies, creating a potential of contamination of these supplies, indicating an uncleaned and unsanitized surface.
· All these observations were confirmed with the Environmental Services Director and/or the Director of Facilities at the time of the observations.

Based on observations and interviews with key personnel on November 30, 2016, it was determined that the facility failed to ensure proper storage of trash.
The 2013 Maine Food Code states in 5-501.14 (A): " Receptacles and waste handling units for Refuse, recyclables, and returnables used with materials containing Food residue and used outside the Food or Eating Establishment shall be designed and constructed to have tight-fitting lids, doors, or covers. "
Finding includes:
· On a tour of the of the hospital waste holding area on November 30, 2016, 2 of 4 dumpsters were observed with 1/3 to ½ of the lids broken off and missing. This observation was confirmed at the time of the observation with the Kitchen Manager.

Based on record reviews and interviews with key personnel on November 30, 2016, it was determined that the facility failed to ensure that temperature and air-flow were maintained at acceptable standards in the Operating Rooms.
Finding includes:
· The facility Surgical Suite Infection Control Policy states in 1. B. " Air changes in the operating room provide at least 20-25 air exchanges per hour and 5 outside air changes per hour. " and in 1. c. it states, " ...Recommended temperature is between 68-73 degrees Fahrenheit ....Cases will not be done until temperature and humidity are within approved limits unless the surgeon determines necessity. "
· On November 30, 2016, at 10:50 AM, in an interview with the HVAC (Heating Ventilation Air Conditioning) Team Leader, he stated that their system is not currently set up to tell them how many air changes are being completed per hour in the operating rooms.
· During a review of the Operating Room (OR) temperature and humidity records for the past 6 months, many of the hourly readings were below the facility ' s standards for operating room temperatures.
· A review of the OR case records for the previous 6 months did not indicate that any cases had been delayed due to OR temperatures being out of range nor were there any notes stating that OR temperatures were out of range at the start of cases.
· In an interview with the OR Manager on November 30, 2016, at 2:50 PM, she stated that they do not document starting cases if the temperature is out of range and have no documentation that they adjust temperatures if they are found to be out of range.

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 Novvember 28, 2016, for the Maine State Fire Marshal ' s Office Life Safety Code survey.

Based on document review and interview with key personnel on November 30, 2016, it was determined that the facility failed to maintain evidence of a properly executed informed consent form.

Finding includes:

A review of 15 inpatient medical records was conducted on November 30, 2016. 1 of 15 medical records (Record LL), failed to contain a scanned copy of the consent form signed by the patient.

The file contained a scanned copy of "page 1" of the form titled "Consent to Treat", which contained a scan of only the first page of the form, and did not contain a scan of the second page, (where the signature of the individual providing consent would be located).

Additionally, the image of the first page showed the identified patient's name on the upper right corner of the page. The form contained the name of another individual, and a checkbox was both checked and circled identifying that other individual as "myself" (indicating that that individual was the patient).

This was confirmed by the Director of Patient Registration on November 30, 2016, at approximately 2:06 PM, who also stated that she was unable to locate the original paper copy of the consent.

Based on record review and interviews with key personnel on November 28, 2016, it was determined that the facility failed to inform a swing bed patient of their swing bed patient rights prior to providing care in 1 of 5 records reviewed (Record A).
Finding includes:
During the review of Record A, conducted on November 28, 2016 , it was determined that the record of the swing bed patient admitted to swing status on November 25, 2016, failed to contain any documentation that the patient had been informed of the swing bed patient rights.
This was confirmed on November 28, 2016, at 11:00 AM by the Swing Bed Coordinator.
On November 29, 2016, at approximately 9:00 AM, the Swing Bed Coordinator informed the surveyor that the patient has since been informed of their swing bed patient rights.

Based on record review and interviews with key personnel on November 29, 2016, it was determined that the facility failed to ensure that the discharging physician completed the required discharge summary per the hospital policy in 1 of 5 swing bed records reviewed (Record C).
The Discharge Summary- Swing Bed Policy states " The discharge summary will be completed within 7 days of discharge. "
Finding includes:
On November 29, 2016, during review of Record C, it was determined that the patient was discharged from the swing bed program on November 15, 2016 (record review was conducted 14 days after discharge). The record failed to contain the required discharge summary .
This finding was confirmed on November 29, 2016, at 10:00 AM by the Director of Quality and Safety.
On November 30, 2016, at approximately 9:00 AM, the Director of Quality and Safety presented the discharge summary for Record C. It was dated November 29, 2016 at 1:59 PM.

Based on document review and interviews with key personnel on November 29-30, 2016, it was determined that the facility failed to inform patients (or their support person) of their visitation rights.

Finding includes:

A review of 15 inpatient medical records was conducted November 29-30, 2016. All 15 medical records failed to contain documentation that the patient (or support person) received notice of their visitation rights (Records X, Y, Z, AA, BB, CC, DD, EE, FF, GG, HH, II, JJ, KK, and LL).

This finding was confirmed with the unit nurse at the time of chart review, and was also confirmed during an interview with the Chief Nursing Officer on November 30, 2016, at approximately 2:00 PM.