HospitalInspections.org

Based on observation, interviews with key personnel and record review, it was determined that the hospital failed to maintain the facility in a manner that ensures the safety of the patients.
Findings include:
On March 29, 2016, a patient who was admitted to the Intermediate Care Unit (IMC) who was receiving treatment for a significant traumatic head injury, which reportedly resulted in the patient suffering serious impairments in decision making abilities and safety awareness. It was reported that the patient was perseverating on leaving the hospital, wanting to return home, and had made several attempts to leave the facility following visits from family. This patient was able to open the window in his/her room wide enough that the patient was able to pass through the opening of the window and fall from the sixth floor of the hospital, resulting in his/her death. The window was noted to be of a design that the right side window sash slides laterally to the left to open for ventilation and an angle bracket was screwed into the bottom rail of the window frame, as a stop, in an effort to prevent the window from creating an opening of more than six (6) inches.
During the investigation, the survey team became aware of an incident that occurred on the Richards Wing of the facility in January, 2016, in which a patient was able to open a similar window beyond the six (6) inch restriction at which the angle bracket was intended to stop it at. Following the January incident, an email from the Administrator on call at the time of the incident was sent out to all nursing staff, nursing supervisors, and the Director of Safety and the Director of Engineering, and other administrative personnel, which stated, "An incident on [Richards Wing] today identified a potential safety issue regarding how wide patient windows can be opened ...we need to determine the scope of this problem." This email also instructed all nursing units to check all patient rooms to assure that the windows cannot be opened greater than six (6) inches, and to report any window that is able to be opened beyond that point for immediate repair.
It was reported that immediately following the incident of March 29, 2016, new window stops were installed that were approximately one half (0.5) inch taller than the stop that was on the window frame on March 29, 2016. The Director of Plant Engineering reported that these new stops were placed on his verbal order following that incident. Additionally; the Director of Plant Engineering stated that all the windows on the (IMC) were secured with taller window stops, window locks actuated, and blocks placed above the sash to prevent lifting of the sash.
During the tour of the sixth floor of the Richards Building, this surveyor asked to see a room that did not have the extended window stop installed, to determine the ability of the interventions implemented to date were able to assure the safety of the patients in the hospital. A room that was occupied, (the patient was out of the room temporarily), was observed. This surveyor and the physical plant surveyor were both able to independently lift the window sash above the stop screwed into the window frame and open the window greater than six (6) inches. It was also noted that by opening the sash approximately three (3) inches, both surveyors were able to lift the sash high enough to actually remove the sash from the window frame. Removal of the window sash would result in an opening of approximately twenty-four (24) inches.
These findings were confirmed by the Director of Plant Engineering on March 31, 2016.
In discussions with the Director of Plant Engineering and the Director of Regulatory Compliance, on April 4, 2016, they stated that the window stops were implemented more than 14 years ago primarily to address air humidity issues. A facility policy dated March 2002 stated: "Policy Title: Window Stop Policy, Policy Summary: It is the policy of Maine Medical Center to properly install window stops on operable windows that require them in patient care areas. Policy: 1. ...All windows in patient care areas must have in place adjustable stops which limit the distance that a window may be opened. 2. For windows that open laterally the stop is positioned so that the window can be opened to a maximum of six (6) inches."
There was no evidence to indicate that a patient risk or safety evaluation was conducted of the window and its operation to determine if utilization of the angle bracket was the most appropriate intervention needed to ensure the window could not open wide enough to create a safety concern. Additionally, the surveyor was informed that there was no evidence of inspection or evaluation of these stops between 2002 and January 2016.
In a follow up interview with the Director of Plant Engineering on April 4, 2016 at 1:45 PM, the surveyor was informed that the window manufacturer was not consulted and that no form of risk evaluation or engineering study was completed prior to the March 29, 2016 incident to determine what the safety risks (ability of a patient to open the window and exit the facility out the window) were and what type of intervention would be most appropriate to mitigate those risks. The surveyor was also informed that there was no intervention other than inspecting and tightening the existing window angle stop brackets after the January 2016 incident.
These findings were confirmed by the Director of Plant Engineering on April 4, 2016.