HospitalInspections.org

Based on review of documentation and interview with key personnel on August 14, 2012, it was determined that the facility failed to be in compliance with the State of Maine "Rules for the Licensing of Hospitals (effective January 1, 2009)."

Section 3.2 Patient Rights in a Critical Access Hospital which stated, "A critical access hospital must protect patient rights and comply with the conditions for patient rights contained in 42 CFR Subsection 482.13."

Forty-two CFR Subsection 482.13(a)(2)(iii) stated: "In its resolution of the grievance, the hospital must provide the patient with written notice of its decision that contains the name of the hospital contact person, the steps taken on behalf of the patient to investigate the grievance, the results of the grievance process, and the date of completion."

Findings include:

1. The facility policy "Patient Complaints and Grievances" stated that "at the conclusion of the investigation, the Grievance shall be notified in writing and provided a brief summary of the investigation and, when appropriate, the steps taken to resolve the matter."

2. Review of the Grievance Log for the past year, (dated 7/1/11-6/30/12), revealed that one (1) of four (4) grievances lacked evidence that the complainant was notified in writing with the resolution to the grievance.

3. This finding was confirmed by the Director of Nursing on August 14, 2012.

Based on tour of facility and interview with key personnel on August 14, 2012, it was determined that the facility failed to assure that electrical patient care equipment was maintained in a safe operating condition. The evidence is as follows:

1. During a tour of the facility, it was observed that one (1) non-medical grade electrical power strip was utilized in both Operating Rooms 1 and 2.

2. This was confirmed by the Director of Environmental Services who immediately removed them from service.

Based on review of the facility ' s documentation and interview with key personnel on August 15, 2012, it was determined that the facility failed to review health care policies as part of the annual program evaluation. The evidence is as follows:

1. During a review of the facility policies, it was revealed that thirteen (13) Hospital Corportation (HC) policies failed to be updated since 2009 and sixty-two (62) policies failed to be updated since 2010.

2. A review of the annual program evaluation was conducted. It failed to include documentation that the policies were updated as required.

3. During an interview with the Director of Quality Assurance, she confirmed these findings and indicated that she was aware that these policies were not updated. She stated, "We were aware of this and had reported it to the parent organization. These policies that haven't been updated are all HC policies, which mean they are organization wide policies, versus hospital specific policies."

Based on review of the facility's documentation and interview with key personnel on August 15, 2012, it was determined that the facility failed to determine whether the utilization of services was appropriate, the established policies were followed, and any changes are needed. The evidence is as follows:

1. A review of the annual program evaluation was conducted. It failed to address whether the utilization of services was appropriate, whether the established policies were followed, and if any changes were needed.

2. This was confirmed with the Director of Quality Assurance. She stated, "We missed it."