HospitalInspections.org

Based on observations and interviews, the hospital failed to ensure areas were clean in 1 of 1 inpatient units observed (Medical/Surgical Unit).

Finding:

On October 15, 2018, at approximately 1:00 PM, the following was observed:

a. A significant accumulation of dust on blinds and bed frames in Rooms #233, #239, #243, and #249;

b. Dusty handrails in the hallway of the Medical/ Surgical Unit;

c. Caulking around the base of the toilet was discolored and a non-intact surface in Rooms #231 and #241;

d. A corroded spray nozzle in Rooms #243 and #251;

e. Torn linoleum in bathroom #239;

f. A cut-out piece of linoleum in bathroom #233; and

g. A separated floor seam in the bathroom doorway of Room #235.

The above findings were confirmed, with the Chief Nursing Officer and the Environmental Supervisor, on 10/15/18 at approximately 2:00 PM.

Based on records reviewed and interviews, the Condition of Participation (COP) for Organizational Structure was not met as evidenced by the failure of the Governing Body to ensure a system was in place to verify services from a crisis agency were furnished by qualified individuals who performed assessments in 1 of 5 sampled Emergency Department patients (Patient #1ES) and 13 other patients seen by the crisis agency since 9/1/18 (Patient 1C, 2C, 3C, 4C, 5C, 6C, 7C, 8C, 9C, 10C, 11C, 12C, and 13C). In addition, based on record reviews, interviews, and observations, the Governing Body failed to ensure hospital policies were implemented in relation to abuse reporting, checking crash carts, and medication storage, administration and errors.

Findings:

§485.627(a) Standard: Governing Body or Responsible Individual also known as C-0241 - Based on record review and interviews, the Governing Body failed to ensure a system was in place to verify assessment and consultation services, from a crisis agency, were furnished by individuals determined to meet minimum qualification determined by the hospital's Governing Body for 1 of 5 sampled Emergency Department patients (Patient #1ES) and 13 other patients seen by the crisis agency since 9/1/18 (Patient 1C, 2C, 3C, 4C, 5C, 6C, 7C, 8C, 9C, 10C, 11C, 12C, and 13C). In addition, based on record reviews, interviews, and observations, the Governing Body failed to ensure hospital policies were implemented in relation to abuse reporting, checking crash carts, and medication storage, administration and errors.

The cumulative effect of the deficient practices resulted in noncompliance with this Condition of Participation.

Based on record review and interviews, the Governing Body failed to ensure a system was in place to verify assessment and consultation services, from a crisis agency, were furnished by individuals determined to meet minimum qualification determined by the hospital's Governing Body for 1 of 5 sampled Emergency Department patients (Patient #1ES) and 13 other patients seen by the crisis agency since 9/1/18 (Patient 1C, 2C, 3C, 4C, 5C, 6C, 7C, 8C, 9C, 10C, 11C, 12C, and 13C). In addition, based on record reviews, interviews, and observations, the Governing Body failed to ensure hospital policies were implemented in relation to abuse reporting, checking crash carts, and medication storage, administration and errors.

Findings:

1. Patient #1ES was seen by a representative of a Crisis Agency on three occasions (twice on 9/26/18 and once on 9/27/18) while in the Emergency Department (ED). A review of the "[Crisis Agency's Name] Crisis Service Assessment Summary and Crisis Plan" form indicated that the crisis worker, who is a Mental Health Rehabilitation Technician/Crisis Service Provider (MHRT/CSP), documents the following: presenting problem, assessment summary, crisis plan/referrals, and the name of a "clinical back-up consulted".

A designation of MHRT/CSP indicates the individual has completed a program recognized in the State of Maine only. The MHRT/CSP Certification applies to MaineCare (Medicaid) "other qualified mental health professionals" providing services to adults, excluding residential services. This includes providers of community support services, case management services, intensive case management services, assertive community treatment, and day support services as outlined in Chapter II of the MaineCare Benefits Manual, Section 17.

The "Service Agreement Between Down East Community Hospital and [the Crisis Agency]", signed by the hospital's President/Chief Executive Officer (CEO) on 8/8/18 and the CEO of the Crisis Agency on 7/30/18 was reviewed. This signed agreement indicated that "[Crisis Agency] also recognizes that its staff providing services on Hospital premises must meet all requirements for the credentialing and contracting of staff by Hospital, in keeping with Joint Commission and other applicable regulatory requirements". However, this signed agreement did not include any language related to the qualifications of individuals provided by the Crisis Agency.

On 10/16/18 at 9:25 AM, the hospital's CEO was interviewed. The following information was obtained during this interview: the hospital does not credential the crisis staff; the CEO was unaware what a MHRT was; and he thought that those who were providing the crisis services were licensed Clinical Social Workers. He also stated that the work the crisis agency staff do is "complicated and is at a high level" and the physicians "refer and default to their decisions". The surveyor discussed that the agreement did not address what qualifications the hospital determined that the crisis workers would be required to have to provide crisis services within the hospital.

On 10/16/18, at 9:40 AM, the Emergency Department Director was interviewed via telephone. He stated that the role of the crisis worker was to assess whether a patient needed inpatient psychiatric care or not. He stated that he felt they had professional training and he relied on the crisis worker.

On 10/16/18 at 10:45 AM, the Vice President (VP) of Quality stated to the surveyor that the governing body had not reviewed the qualifications of the crisis workers. She indicated that she looked up what a MHRT was today and stated, "it's not different than working at Walmart"; she indicated that she did not know what a MHRT was; and the crisis workers do "assessments" and talk with the patients.

On 10/17/18, the hospital provided a list of 14 patients (1C, 2C, 3C, 4C, 5C, 6C, 7C, 8C, 9C, 10C, 11C, 12C,13C and 1ES) who had been seen by the crisis agency since 9/1/18. A review of the "[Crisis Agency's Name] Crisis Service Assessment Summary and Crisis Plan" form indicated these patients were all seen by a MHRT/CSP.

2. The Hospital's "Staff Treatment of Patient and Resident" policy and procedure, last reviewed in 10/17, indicated the following: "all alleged violations of this policy will be reported immediately to the CEO [Chief Executive Officer] and the CNO [Chief Nursing Officer]. All alleged violations of this policy will be reported to other officials in accordance with State law (including to the State survey and certification agency). All allegations will be thoroughly investigated and results reported to the CEO (or designee), CNO, and other State officials within 5 working days."

On 10/16/18, surveyors reviewed a patient complaint that involved Patient 1A which occurred on 7/27/18. The information on the "Incident Information" form indicated "complaint regarding the treatment of a elderly patient with dementia in the emergency department when they were trying to discharge to patient to patient home with family patient was agitated and uncooperative." The report form indicated that the Emergency Department (ED) Director had been notified by the Supervisor that a specific nurse had displayed inappropriate behavior, the nurse was sent home, the VP of Quality made a post discharge phone call to the patient, an investigation was being done, and the plan was to meet with the nurse on 8/2/18. Documentation on the report by the VP of Quality indicated the following: "call was placed to the [specific family member] the Monday after the incident, she indicated that the staff that attempted to get her [relation to family member] into the car upon discharge what she saw was terrible, she felt they were rough. She was advised that an investigation would be done about this issue. Nurse involved in the incident subsequently resigned."

A memo, dated 7/30/18 at 10:30 AM, written by the VP of Quality, that was attached to the "Incident Information" form was reviewed. This memo indicated the the VP of Quality spoke with the patient's relative regarding the patient's visit to the ED. The family member indicated that the patient was put into a wheelchair and taken outside to the car. It was at this time the relative "felt that the care was unacceptable and rough, she stated that 3 nurses tried to get her [specific relative] into the vehicle. They were all yelling at [him/her] to sit up, get in the care etc. she said at one point it looked like her [relative's] feet were over [his/her] head as they tried to shove [him/her] into the vehicle."

On 10/16/18, in an interview which began at 1:35 PM, the VP of Quality was asked if this incident had been reported as an allegation of abuse to State officials including the state licensing and certification agency. She indicated that it has not been reported and that the incident had been handled as a code of conduct incident.

On 10/17/18 at 10:35 AM, the CNO was interviewed. She indicated that on 9/27/18 she was notified that the nurse had used inappropriate language (the "f" word) in front of the patient. She indicated that the conversation between the VP of Quality and the patient's family member had not been shared with her.

Based on the interviews, the hospital's policy and procedure related to "Staff Treatment of Patient and Resident" was not followed as the allegation of abuse was not reported to State Officials, including the state licensing and certification agency, and the results were not reported.

3. The hospital's "Emergency Medications" policy and procedure indicated, "Down East Community Hospital maintains mobile supplies of emergency equipment and medications (crash cart) in patient care areas of the hospital". The procedure indicated the "nurse will inspect the seal's integrity on every shift and document on the attached clipboard. The nursing staff will inspect the crash cart for outdates monthly ...." The following was noted:

a. On 10/17/18, at 9:20 AM, a package of Pedi-Padz, with an expiration date of 4/1/20/18, was observed on the crash cart on the Medical Surgical Unit. On 10/17/18, at 9:36 AM, Employee #5 confirmed this finding.

b. On 10/17/18, at 9:20 AM, a review of the the "Crash Cart Checklist" for the crash cart located on the Medical Surgical Unit was completed. There was no evidence that the seals integrity was checked on the PM shift on 8/28/18, 8/29/18 and 10/4/18.
On 10/17/18, at 9:36 AM, Employee #5 confirmed that the "Crash Cart Checklist" was not completed as noted above.

c. On 10/17/18, at 9:36 AM, two opened packages of Pedi Electrodes, with an expiration date of 7/2018, and an unopened package of Infant Electrode Pads, which an expiration date of 9/2018, were observed on the crash cart in the Emergency Department. On 10/17/18, at 9:36 AM, Employee #6 confirmed this finding.

d. On 10/17/18, at 9:50 AM, a review of the the "Crash Cart Checklist" for the crash cart located in Cardiac Rehab Department was completed. There was no evidence that the seals integrity was checked on the AM or the PM shift on 9/5/18, 9/6/18, 9/8/18, and 9/27/18, and the PM shift on 9/4/18, 9/7/18, 9/10/18 through 9/14/18, 9/17/18 through 9/21/18, 9/24/18 through 9/26/18, and 9/28/18. On 10/17/18, at 9:50 AM, Employee #8 stated the hours of operation of the Cardiac Rehab Department are 8:00 AM to 2:00 PM Monday, Wednesday, and Friday and that the Infusion Clinic Nurse checks the crash cart on Tuesdays and Thursdays.

e. On 10/17/18, at 11:27 AM, a review of the the "Crash Cart Checklist" for the crash cart located in Cardiopulmonary Services area was completed. The crash cart in this area was to be checked at the beginning of the shift. There was no documentation that indicated that the cart was checked before each shift. In addition, the documentation indicated "incomplete" from 8/26/18 through 9/4/18, "cart stocked" "but still not completed" on 9/5/15, "still not completed" from 9/6/18 through 9/8/17; "partially stocked incomplete" on 9/9/18; incomplete on 9/10/18 through 9/12/18. In addition the "Crash Cart Checklist" was not completed before each shift from 8/26/18 through 10/17/18. On 10/17/18, at 11:27 AM, Employee #4 confirmed that the Cardiopulmonary Services area completes the "Crash Cart Checklist" daily, but not every shift. Employee #4 also indicated that a Registered Nurse made a list of old and outdated items and gave the list of items to the supply person to order on 8/26/18 but these items were not replaced until 9/12/18.

4. A review of the Surgical Services policy, "Crash Cart," was completed. This policy stated, "During weekend hours and holidays, it is the responsibility of the manager on duty, nursing supervisor to check the crash cart/defibrillator and document this on the checklist ...Crash cart check list form is part of this policy." There was no evidence that the Surgical Services Department Adult and Pediatric Crash Cart was checked on 9/1/18, 9/2/18, 9/3/18, 9/15/18, 9/16/18, and 9/29/18. On 10/17/18, at 11:45 AM, Employee #9 confirmed this finding.

5. Based on observation and interviews, the hospital failed to ensure a medication was stored, per their policy, for 1 of 1 medications observed unsecured at the bedside. Please see C-0276 for details.

6. Based on record reviews and interviews, the hospital failed to ensure that the hospital's policy was implemented in relation to medication errors for 4 of 5 randomly selected patients (Patient #25, #26, #27, and #28). Please see C-0277 for details.

7. Based on record review and interview, the hospital failed to maintain the standard of practice related to medication administration and follow their policy for 1 of 5 randomly selected reports reviewed (Patient #24). Please see C-297 for details.

Based on observation and interviews, the hospital failed to ensure a medication was stored, per their policy, for 1 of 1 medications observed unsecured at the bedside.

Finding:

The hospital's "Medication Administration" policy, last reviewed 9/17, was reviewed. The medication storage section of the policy indicated that medications will be securely stored in the Pyxis cabinets, locked medication carts or in the secured medication room not located in general patient areas. The policy did not indicate that medications would be stored at the patient's bedside.

On 10/15/18, at 1:05 PM, a tube of Nystatin Ointment was observed stored at Patient #7's bedside.

On 10/16/18, at 3:30 PM, the Registered Nurse Manager for the Medical Surgical Unit, stated that she spoke with the Physician who ordered the Nystatin and this medication was "not ordered to be at the bedside."

On 10/17/18, at 10:20 AM, the Chief Nursing Officer confirmed that the hospital policy on "Medication Administration" did not address patient medication at the bedside. She indicated it is not acceptable standard of practice in their hospital.

Based on record reviews and interviews, the hospital failed to ensure that the hospital's policy was implemented in relation to medication errors for 4 of 5 randomly selected patients (Patient #25, #26, #27, and #28).

Findings:

The hospital's "Adverse Drug Events" (ADE) policy states: "the healthcare professional caring for the patient when the ADE occurs will document the date and time of reaction, type of reaction, etc. in the patient's clinical record (progress notes) and on the ADR [Adverse Drug Reaction] Reporting Form." It adds that "a record shall also be entered by the healthcare provider of when the attending physician was notified of the ADE, when the patient and /or their family were notified and the resolution." In addition, this policy addressed medication errors.

1. An incident report, dated 8/09/18, indicated Patient #25 had an order for Zofran to be given intravenous (IV) push every four hours. The report indicated the Zofran was given at 10:17 AM and 11:30 AM, 1 hour and 13 minutes apart. On 10/17/18, at 1:30 PM, the ED (Emergency Department) Director reviewed the record. She confirmed there was no documentation in the patient's record that the patient nor the physician were notified of this medication error.

2. An incident report, dated 9/09/18, indicated Patient #26 had an order for Oxycodone IR (Immediate Release). The report indicated that Oxycodone CR (Controlled Release) was given, not Oxycodone IR. On 10/17/18, at approximately 1:35 PM, the ED Director reviewed the record. She confirmed there was no documentation in the patient's record that the patient or the physician were notified of this medication error.

3. An Incident report, dated 10/03/18, indicated Patient #27 had an order for Oxycodone/Acetaminophen. The report indicated that Acetaminophen/Codeine was administered, instead of Oxycodone/Acetaminophen. On 10/17/18, at 1:40 PM, the ED Director reviewed the record. She confirmed there was an error and that there was no documentation in the patient's record that the patient or the physician were notified of this medication error.

4. An incident report, dated 9/22/18, indicated Patient #28 had an order for Pregabalin 75 mgs (milligrams). The report indicated that the patient only received Pregabalin 25 mgs, not the ordered 75 mgs. On 10/17/18, at 1:48 PM, the Manager of the Medical/Surgical/Obstetrics Unit reviewed the record. She confirmed that there was no documentation that the patient or the physician were notified of this medication error.

Based on observations and interviews, the hospital failed to have a system to maintain equipment to ensure a sanitary environment to prevent potential infection in 2 of 2 Operating Rooms (OR #1 and #2)

Findings:

1. On 10/15/18, at 1:15 PM., two stools with rusty castors were observed in OR #1 and #2.

2. On 10/15/18 at 1:15 PM, 17 dimed size openings were observed in the vinyl of two sections of the operating table and there were frayed corners. These openings and frayed corners created a surface that could not be cleaned and sanitized.

The above findings were confirmed at the time of the observations.

Based on record review and interview, the hospital failed to maintain the standard of practice related to medication administration and follow their policy for 1 of 5 randomly selected reports reviewed (Patient #24).

Finding:

It is standard practice that medication documentation is expected to occur after the actual administration of the drug to the patient. The hospital's "Medication Administration" policy and procedure indicates "Medications are administered immediately after the medication is prepared without a break in the process by the individual who prepares the dose." "This will be done using two hospital approved identifiers i.e.[for example], name band or DOB [date of birth] and asking the patient to state his/ her name." "Document administration via Med [medication] Verify/Electronic documents or on the appropriate paper documents." The steps of the medication administration procedure indicate that documentation occurs after administration of medications, not before.

An incident report, dated 7/31/18, indicated there was a Hydromorphone injection removed from the Pyxis (a secure medication storage area) for Patient #24. The report indicated the medication was documented as being administered on the Medication Administration Record (MAR) and in the Nursing Notes. The report also indicated that the Hydromorphone was then documented as being wasted, which means that the medication was destroyed and not given.

On 10/17/18, at 12:58 PM, the Manager of Medical/Surgical/Obstetrics Unit reviewed the record. She confirmed the documentation indicated the medication was administered. She confirmed the medication was not given and that the hospital's policy related to medication administration documentation was not followed. She then explained that the hospital utilizes a "medicine verify system" which is done at the bedside at the time of administration.