The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTHERN LIGHT MAYO HOSPITAL 897 WEST MAIN STREET DOVER FOXCROFT, ME 04426 May 17, 2013
VIOLATION: ORGANIZATIONAL STRUCTURE Tag No: C0960
Based on record review, policy review and interview with key personnel on May 7, 2013, it was determined that the hospital governing body:

1. Failed to ensure that the doctors were responsible for the CAH's health care activities (see Tag 257);

2. Failed to deliver health care to patients according to the hospital policies and procedures (see Condition of Participation, Provision of Services, Tag 270); and

3. Failed to recognize problems at the time of care and review them as part of their quality program after being informed of a patient complaint (see Condition of Participation, Periodic Evaluation & QA Review, Tag 330).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: RESPONSIBILITIES OF MD AND DO Tag No: C0981
Based on record review, policy review and interview with key personnel on May 7 -17, 2013, it was determined that the doctors failed to be responsible for the CAH's health care activities.

Findings include:

Patient Care Issues

1. Patient A's History and Physical documented that he/she was admitted from the Emergency Department (ED) on August 26, 2012 with a chief complaint of abdominal pain after arriving in the ED the night before. Patient A's vital signs listed a temperature of "98.1," and a pulse of 73. Patient A had pain "constant and worsening overnight associated with some nausea..." The "Assessment and Plan" noted "likely viral gastroenteritis, rule out early partial small bowel obstruction. Will admit for IV fluids."

2. Fauci, Et.al. stated in Harrison's Principles of Internal Medicine 17 th edition (2008, p. 1914): "Purely nonoperative therapy is safe only in the presence of incomplete obstruction and is best utilized in patients without increasing abdominal pain or leukocytosis [an abnormally large increase in the number of white blood cells in the blood]."

3. Nursing documentation of pain indicated that the patients pain level increased from 6/10 (six on a scale of one to ten) at 1400 to 9/10 by 1532 on August 26, with resulting changes in pain medication from Fentanyl to Dilaudid, to change to PCA (patient-controlled analgesia) of Dilaudid at 1659 on August 26, 2012. Documentation indicated that the patient's pain remained elevated at 6/10 throughout August 27, 2012, even with the PCA.

4. Patient A's laboratory results included a white blood cell count of 9.2 on August 26, 2012 at 0545 and an increased white blood cell count of 18.8 at 0640 on August 27, 2012.

5. The Radiology report, completed on August 26, 2012 at 1636 indicated "Partial SBO (small bowel obstruction). Degree of bowel dilatation is similar to what was seen previously."

6. A review of the transcript from the transfer center, and the telephone call recordings indicated that Physician B had called at 1759 on August 27, 2013 and talked to the surgeon, and informed the tertiary care center that the patient could be treated conservatively at Mayo Regional Hospital. Throughout August 26 to August 28, the CAH was in contact with the tertiary care center, awaiting availability of a surgical bed, and continued to treat the patient conservatively without attempting to contact another hospital for surgical consultation, in spite of the documented deterioration in Patient A's condition.

7. The "Transfer/Discharge Summary" dated August 28, 2013 documented that Patient A was later transferred to another general hospital for "small bowel obstruction, in need of Surgical evaluation" on August 28, 2013.

8. Fauci, Et.al. stated in Harrison's Principles of Internal Medicine 17 th edition (2008, p. 1914): "The overall mortality rate for obstruction of the small intestine is about 10%. While the mortality rate for nonstrangulating obstruction is 5-8%, the mortality rate for strangulating obstruction ranges from 20 to 70%. Since strangulating small bowel obstruction is always complete, surgical interventions should always be undertaken in such patients after suitable preparation."

9. The reviewer notes in the OI Report (Occurrence Insight Report) documented that this patient had 110 cm (centimeters) of ischemic intestine removed due to torsion. The patient reported that "I had a small bowel resection for a volvulus [abnormal twisting of the intestine causing obstruction] at another hospital and was in the hospital nine [9] days."

Failure to Review Quality of Care

10. The OI Report stated: "This deserves discussion on two issues. Firstly, the reasonability of the hospitalist service accepting patients that may have a surgical issue, without adequate surgical coverage. Secondly, when and how to determine when we should contact another facility for a patient's transfer." Both deserve discussion within the next hospitalist service meeting, and subsequently with the emergency service. Likely, final determinations should be shared at the MEC [Medical Executive Committee] and Medical Staff meetings."

11. In spite of the documentation indicating the patient care concerns would be reviewed, the committee meeting minutes for the Medicine Service Meeting, the Emergency Service meeting, Medical Staff Meeting, Committee on Quality of Care and Professional Performance, Patient Safety Committee all lacked evidence that the issues were discussed at these committees.

12. In a discussion with the Vice President of Quality, on April 23, 2013, she stated that the patient complaint and accepting a patient with no bed available (delay in transferring) should have been brought up in committee, but she wasn't "sure where".
VIOLATION: PROVISION OF SERVICES Tag No: C1004
Based on review of clinical record, review of policies and procedures, review of information provided and interviews with key staff April 23, 2013 and May 17, 2013, it was determined that the CAH:

1. Failed to ensure that the doctors were responsible for the CAH's health care activities (see Tag 257);

2. Failed to deliver health care to patients according to the hospital policies and procedures (see Tags 271 and 335);

3. Failed to deliver nursing services required to meet the needs of the patients (see Tag 294); and

4. Failed to recognize problems at the time of care and review them as part of their quality program after being informed of a patient complaint (see Tags 257, 335 and 337).


The cumulative effects of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: PATIENT CARE POLICIES Tag No: C1006
Based on record review, policy review and interview with key personnel on May 17, 2013, it was determined that the facility failed to assure that health care services were furnished in accordance with written policies.

Findings include:

1. The facility policy "Progress Notes" indicated: "progress notes must give a pertinent chronological report of the patient's course in the hospital, reflect any changes in condition and reflect results of treatments".

2. Patient A's History and Physical documented that he/she was admitted from the Emergency Department (ED) on August 26, 2012 with a chief complaint of abdominal pain after arriving in the ED the night before. Patient A's vital signs listed a temperature of "98.1," a pulse of 73 and "audible bowel sounds all 3 [sic] quadrants.".

3. Documentation in the nursing notes, indicated that on August 27, 2012 at 2000, the patients bowel sounds were absent. On August 28, 2012 at 0146, the patient had bowel sounds absent, his/her temperature was 100.7, and his/her pulse was elevated. Physician B was "notified of the patient pulse" at 0600 on August 28, 2013.

4. The medical record made no indication of the physician writing a progress note about the absent bowel sounds, or being notified by the nursing staff for an elevated pulse.

5. A review of the transcript from the transfer center and the recorded telephone contacts indicated that Physician B had called at 1759 on August 27, 2013 and talked to the surgeon, and informed the tertiary care center that the patient could be treated conservatively at Mayo Regional Hospital.

6. The medical record lacked documentation in the physician progress notes to indicate that this had been discussed with the tertiary care center and the determination to hold the patient.

7. The above findings were discussed with the Vice President of Quality on May 17, 2013.
VIOLATION: NURSING SERVICES Tag No: C1046
Based on record review and interview with key personnel on May 17, 2013, it was determined that the facility failed to assure nursing services met the needs of the patients.

Findings include:

1. Patient A's History and Physical documented that he/she was admitted from the Emergency Department (ED) on August 26, 2012 with a chief complaint of abdominal pain after arriving in the ED the night before. Patient A's vital signs listed a temperature of "98.1," a pulse of 73 and "audible bowel sounds all 3 [sic] quadrants.".

2. Documentation in the nursing notes at 2000 on August 27, 2013 indicated, "do not hear bowel sounds at this time".

3. Documentation in the nursing notes at 0146, August 28, 2013, indicated, "Bowel Sounds absent, monitor per nursing supervisor."

4. In spite of the nursing documentation of the deterioration in the patient's condition, nursing documentation lacked evidence that the physician was notified of these changes.

5. The above findings were discussed with the Vice President of Quality on May 17, 2013.
VIOLATION: PERIODIC EVALUATION & QA REVIEW Tag No: C0330
Based on review of patient records, review of facility complaint system (AVATAR) review of policies and procedures and interview with key personnel, on April 23, 2013 and May 17, 2013, it was determined that the CAH:

1. Failed to ensure that the doctors were responsible for the CAH's health care activities (see Tag 257);

2. Failed to deliver health care to patients according to the hospital policies and procedures (see Tags 271 and 335);

3. Failed to deliver nursing services required to meet the needs of the patients (see Tag 294); and

4. Failed to recognize problems at the time of care and review them as part of their quality program after being informed by a patient complaint (see Tags 257, 335 and 337).

The cumulative effect of these deficient practices resulted in this Condition of Participation being out of compliance.
VIOLATION: PERIODIC EVALUATION Tag No: C0335
Based on record review, policy review and review of Mayo's Peer Review, and interview with key personnel on May 17, 2013, it was determined that the facility failed to determine whether the utilization of services was appropriate, and the established policies were followed.

The findings include:

Progress Notes Policy

1. The facility policy "Progress Notes" indicated: "progress notes must give a pertinent chronological report of the patient's course in the hospital, reflect any changes in condition and reflect results of treatments". In spite of this, Patient A's record contained no documentation of the physician writing a progress note about the absent bowel sounds, or being notified by the nursing staff for an elevated pulse. Additionally, the medical record lacked documentation in the physician progress notes to indicate that this had been discussed with the tertiary care center and the determination had been made to hold the patient (see Tag 257).

Peer Review Policy

2. The facility policy " Peer Review" directed that peer review of medical records may be done on the following cases: any sentinel event, unexpected adverse events, unplanned transfers, specific aspects of care, patient complaints and concerns about utilization of services. It goes on to direct, "When a case is recognized to be "outside the established criteria", it will be forwarded to a physician member of the appropriate Service or Committee, to be reviewed at the next meeting".

3. Review of the Medical Service Minutes from August 2012 to April 2013, lacked evidence or peer review of the patient complaint related to delay in referral to another hospital when there were no beds available at the first hospital where the Hospitalist had attempted to transfer the patient for a surgical consult.

4. The Mayo Peer Review form provided by the Vice President of Quality lacked evidence that the complaint was reviewed as part of the facility peer review, per CAH policy.

5. In a discussion with the Vice President of Quality, on April 23, 2013, she stated that the patient complaint and accepting a patient with no bed available (delay in transferring) should have been brought up in committee, but she wasn't sure where.

Utilization of Services

6. The CAH failed to evaluate the utilization of services for Patient A (see Tag 337).
VIOLATION: QUALITY ASSURANCE Tag No: C0337
Based on record review and interview with key personnel on April 23, 2013 and May 17, 2013, it was determined that the CAH failed to evaluate the quality and appropriateness of the treatment furnished and of the treatment outcomes.

Findings include:

1. The OI Report (Occurrence Insight Report), part of the AVATAR complaint system, documented that the CAH received a complaint on September 23, 2013 about an "issue with care provided" to Patient A (see Tags 257 and 270).

2. The OI Report stated: "This deserves discussion on two issues. Firstly, the reasonability of the hospitalist service accepting patients that may have a surgical issue, without adequate surgical coverage. Secondly, when and how to determine when we should contact another facility for a patient's transfer. Both deserve discussion within the next hospitalist service meeting, and subsequently with the emergency service. Likely, final determinations should be shared at the MEC [Medical Executive Committee] and Medical Staff meetings."

3. Review of the committee meeting minutes for the Medicine Service Meeting and the Emergency Service meeting, Medical Staff Meeting, Committee on Quality of Care and Professional Performance, Patient Safety Committee, and the Executive Committee all lacked documentation that these patient care issues discussed.

4. The above findings findings were discussed with the Vice President of Quality on May 17, 2013 at 11:00 AM. She stated that "I do remember that one. We called and they said we'd take [him/her] in the morning and when we called in the morning to confirm, they [the tertiary care center] put us off again. We were very frustrated. We felt it was a near miss."

5. No documentation of any investigation of this incident was provided by the CAH.