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.

EASTERN MAINE MEDICAL CENTER PO BOX 404 BANGOR, ME 04401 March 9, 2018
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
Based on observations, document reviews, and interviews, the hospital failed to maintain patient care areas in a manner that minimized the risk of infection transmission and cross contamination in 1 of 2 locations (main campus). In addition, the hospital failed to ensure that food, that would be served to patients, was served in a manner to minimize the risk of contamination for 1 of 1 observations of the meal tray assembly line (March 5, 2018 at lunch).

Findings include:

1. On March 6, 2018, from 8:10 AM to 2:45 PM, during a tour of the main campus, with the Maintenance Director, the surveyor observed unsealed corkboards in the following areas: on Grant 4, Rooms #407 and #434; on Grant 6 in Room #621; on Merritt 3 in Room #307; on Phillip-Oliver 3 in Rooms #389 and #397; on Phillip-Oliver 5 in Rooms #149, #150, #151, #152, and #160; and in the Grant Intensive Care Unit in Rooms #135 and #136.

On March 7, 2018, from 11:00 AM to 2:45 PM, during a tour of the Webber Building (main campus area), with the Maintenance Operations Manager, the surveyor observed unsealed corkboards within the Infectious Disease Professional Service, in Exam Rooms #1, #2, and #3.

These unsealed corkboards created a surface which could not easily be cleaned and sanitized.

2. On March 5, 2018, from 9:50 AM to 2:45 PM, during a tour of the main campus, with the Maintenance Director the following was observed:

a. In Nuclear Medicine, in Room #187, there was an intravenous (IV) pole with rust on the base.

b. On Penobscot in Room #175 and in the Grant 6 soiled utility room, there was a linen cart that had an accumulation of debris on the base.

c. On Grant in Rooms #167 (public restroom), #860, #873, #874, #876, and #878, the cove base was peeling off.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed, with the Maintenance Director, at the time of the observations.

3. On March 6, 2018, from 8:10 AM to 2:45 PM, during a tour of the main campus, with the Maintenance Director the following was observed:

a. On Grant 5, in the West Side Court, a wheel chair had torn vinyl on the seat.

b. On Grant 5, in Room #519, a vinyl chair was worn approximately three inches at the top of the chair back.

c. On Grant 4 in Rooms #408, #412, and #427, on Grant 5 in Room #524, on Merritt 3 in Rooms #306 and #313, and on Phillip-Oliver 5 in Room #151, there was cracked and/or broken flash coving.

d. On Phillip-Oliver 5, in Room #144, the cove base missing from a section of the wall.

e. On Grant 5, in Room #525, there was a rusted biohazard can.

f. On Merritt 3, in Rooms #302 and #327, there was a linen cart that had an accumulation of debris on the base.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed, with the Maintenance Director, at the time of the observations.

4. On March 7, 2018, from 8:15 AM to 11:00 AM, during a tour of the main campus, with the Maintenance Director, the surveyor observed, in Neurology, Room #4, a worn, non-intact surface on an anti-fatigue mat. This worn area created a surface which could not be easily cleaned and sanitized. This finding was confirmed, with the Maintenance Director, at the time of the observation.

5. On March 7, 2018 from 11:00 AM to 2:45 PM, during a tour of the Webber Building (main campus area), with the Maintenance Operations Manager, the following was observed:

a. Within the Pediatric Specialty Care, in Exam Room #9, the exam table had worn, non-intact vinyl on the edge.

b. Within Focus Eye Care of Maine, in Room #6, the exam chair had worn and stained plastic arm sleeves which were covering torn vinyl.

d. Within the Webber Laboratory, in Rooms #3, #4, and #5, the arm of the chairs had worn/torn vinyl.

All of the areas noted above created a surface which could not easily be cleaned and sanitized.

The above findings were confirmed, with the Maintenance Operations Manager, at the time of the observations.

7. On March 7, 2018 at approximately 2:00 PM, during an observation of a surgical procedure in Operating Room 15, a surveyor observed two stainless steel tables and one rolling stool that had rusty castors. Additionally, one of the stainless steel tables was observed to have corroded aluminum castors that were unable to be properly sanitized. The rust areas on the steel tables and the stool and the corroded area on one of the tables created a surface which could not be easily cleaned and sanitized.

These findings were confirmed, by the Associate Vice President of Patient Care Services, on March 7, 2018, at approximately 2:30 PM.

6. On March 5, 2018, from 11:08 AM to 12:30 PM, a surveyor observed the meal tray assembly line. During this observation, the following issues were identified:

a. A staff member, who was at the steam table checking the temperature of the soup prior to it being served, was not wearing a hair net. This observation was confirmed by the Production Manager at 11:18 AM. Hairnets are required to be worn whenever food is being prepared or served in order to prevent contamination of the food.

b. On four occasions (11:36 AM, 11:38 AM, 11:39 AM, and 11:41 AM), the Short Order Cook was observed touching his glasses with his gloved hand and at 11:40 AM he was observed picking up a clipboard and a pen with his gloved hands. At 11:43 AM, the Cook used his gloved hand to pick up French Fries, place the French Fries on a plate, and hand the plate to another assembly line staff member. The Cook had not removed his gloves and washed his hands between touching his glasses, the clipboard, and the pen and touching the French Fries. This observation was discussed with the Production Manager at 11:46 AM.
VIOLATION: PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS Tag No: A0147
Based on observations and interview, the hospital failed to ensure documentation on computer screens was kept confidential in 3 of 5 outpatient clinics located at Cancer Care of Maine (Rheumatology and Anemia Clinic; Pediatric Oncology Area; and the Breast Center Clinic Nursing Station).

Findings:

1. On March 6, 2018, at 10:50 AM, surveyors could easily read patient information on the computer through the glass at the nursing station in the Rheumatology & Anemia Clinic.

2. On March 6, 2018, at 11:15 AM, surveyors could easily read patient information on the computer through the glass at the nursing station in the Pediatric Oncology area.

3. On March 6, 2018, at 2:15 PM, surveyors could easily read patient information on the computer through the glass at the nursing station in the Breast Center Clinic.

The above findings were confirmed with the Executive Director of Cancer Care of Maine at the time of the observations.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observations, interviews, and record reviews, the hospital failed to ensure safety inspections of electrical items were performed annually, per their protocols, in 1 of 2 locations (main campus).

Findings:

On March 5, 2018, at 10:10 AM, the Clinical Engineer stated that the hospital performs an inspection of electrical items on an annual basis and uses color coded stickers to indicate the year in which the item was inspected. A red sticker indicates the item was inspected in 2017 and a green colored sticker indicates the item was inspected in 2018.

1. On March 5, 2018, from 10:25 AM to 11:00 AM, during a tour of the main campus, with the Maintenance Director, four Intravenous (IV) Pumps were observed without a red or green sticker. The lack of a red or green sticker indicated that the pumps were not inspected in 2017 or yet in 2018. The pumps observed were as follows: Pump # 7 and # 7 located in the Pyxis room in the Interventional Preparatory and Recovery area (10:25 AM); Pump # 5 located in Room 167 in the Interventional Preparatory and Recovery area (10:37 AM); and Pump # 5 located in the Trauma Room in the emergency room (11:00 AM).

These findings were confirmed, with the Maintenance Director, at the time of the observations.

The "Clinical Engineering Asset Detailing Report", provided to the surveyor on March 9, 2018, indicated the IV pumps were last inspected as follows: Pump # 7 on 9/03/2015; Pump # 7 on 11/18/2016; Pump # 5 on 12/29/2016; and Pump # 5 on 12/20/2016.

2. On March 5, 2018, at 12:55 PM, a surveyor observed two stand-on floor scales (# 4 and # 4) in an alcove on the Cardiac Telemetry Unit. Neither of these scales had a red or green sticker indicating they had been inspected in 2017 or yet in 2018.

This finding was confirmed, with the Maintenance Director, at the time of the observation.

The "Clinical Engineering Asset Detailing Report", provided to the surveyor on March 9, 2018, indicated the stand-on floor scales were last inspected as follows: # 4 on 5/03/2016 and # 9 on 5/03/2016.

On March 9, 2018 at 11:45 AM, the Clinical Engineer confirmed the stand-on floor scales had not been scheduled yet for an inspection.

3. On March 6, 2018, from 9:45 AM to 11:00 AM, during a tour of the main campus, with the Maintenance Director, two IV Pumps were observed without a red or green sticker. The lack of a red or green sticker indicated that they were not inspected in 2017 or yet in 2018. The pumps observed were as follows: Pump # 7 in Room #633 on the Grant 6 unit and Pump # 0 in Room 136 in the Grant Intensive Care Unit.

These findings were confirmed, with the Maintenance Director, at the time of the observations.

The "Clinical Engineering Asset Detailing Report", provided to the surveyor on March 9, 2018, indicated the IV pumps were last inspected as follows: Pump # 7 on 9/03/2015 and Pump # 0 on 12/06/2016.
VIOLATION: PATIENT SAFETY Tag No: A0286
Based on observations and document review, the hospital failed to ensure that a submitted and approved plan of correction related to unsealed corkboards was implemented and monitored for 1 of 1 previously cited issue. This failure resulted in a repeat deficiency.
Finding:

During a survey on January 30, 2017 to February 2, 2017, the hospital was found to be in noncompliance with standard 482.13(c)(2) Patient Rights: Care in Safe Environment (A-0144) and one of the issues identified and cited involved corkboards in patient care areas that could not be easily cleaned and sanitized. On March 13, 2017, the hospital submitted a plan of correction which indicated "all of the corkboards have been painted to provide a cleanable surface.... We will work with EVS and Nursing to ensure that we aren't making new pin holes in existing corkboards in the patient rooms".

During this survey, the facility was found again to be in noncompliance with 482.13(c)(2) Patient Rights: Care in Safe Environment (A-0144) as evidenced by the following:

On March 6, 2018, from 8:10 AM to 2:45 PM, during a tour of the main campus, with the Maintenance Director, the surveyor observed unsealed corkboards in the following areas: on Grant 4, Rooms #407 and #434; on Grant 6 in Room #621; on Merritt 3 in Room #307; on Phillip-Oliver 3 in Rooms #389 and #397; on Phillip-Oliver 5 in Rooms #149, #150, #151, #152, and #160; and in the Grant Intensive Care Unit in Rooms #135 and #136.

On March 7, 2018, from 11:00 AM to 2:45 PM, during a tour of the Webber Building (main campus area), with the Maintenance Operations Manager, the surveyor observed unsealed corkboards within the Infectious Disease Professional Service, in Exam Rooms #1, #2, and #3.

These unsealed corkboards created a surface which could not easily be cleaned and sanitized.
VIOLATION: PHYSICAL ENVIRONMENT Tag No: A0700
Based on observations, interviews, and document reviews, it was determined that the Condition of Participation for Physical Environment was not met as evidenced by the hospital's failure to have a system in place to ensure windows did not fully open. This failure created a potential safety hazard on 1 of 4 inpatient units (Phillips Oliver 3). A determination of immediate jeopardy was made, under standard 482.41(a) Maintenance of Physical Plant (A701), for the hospital's failure to ensure a safe environment.

Findings:

Standard: 482.41(a) Maintenance of Physical Plant also known as A701 - Based on observations, interviews, and document reviews, the hospital failed to have a system in place to ensure windows did not fully open, thus creating a safety hazard in 1 of 4 inpatient units (Phillips Oliver 3). This failure created an environment that had the potential for serious to life threatening injuries to a patient who fell or jumped from the window; thus, a determination of immediate jeopardy was made. See A-0701, finding #1, for details.

The cumulative effect of this deficient practice resulted in noncompliance with this Condition of Participation.
VIOLATION: MAINTENANCE OF PHYSICAL PLANT Tag No: A0701
Based on observations, interviews, and document reviews, the hospital failed to have a system in place to ensure windows did not fully open, thus creating a safety hazard in 1 of 4 inpatient units (Phillips Oliver 3). This failure created an environment that had the potential for serious to life threatening injuries if a patient fell or jumped from the window; thus, a determination of immediate jeopardy was made. In addition, based on observations and interviews, the hospital failed to ensure carts, containing sharp items, were not accessible to unauthorized individuals in 1 of 8 outpatient clinics (Radiology and Oncology Clinic) and in the Emergency Department.

Findings:

1. On March 6, 2018, at 2:10 PM, on tour with the Maintenance Director, a surveyor observed that the window could be fully opened in Room #389 on the Phillips Oliver 3 Unit. There was a two story drop, outside the window, to the next surface and this window opening was large enough for an individual to fall out or jump out. The Maintenance Director stated that someone must have removed the two screws that kept the window from opening. The Maintenance Director called a staff person to secure the window.

At 2:20 PM, the surveyor observed that the window, in Room #389, had been secured and no longer could open.

Phillips Oliver 3 Unit is a ten bed neurological rehabilitation unit that treats patients who have had a traumatic brain injury, stroke, and other patients requiring acute rehabilitation. This unit is located on the third floor of an older building within the hospital and is connected to another unit via a hallway.

At 3:30 PM, the surveyors met with the Maintenance Director and asked him what the hospital's process was in relation to checking that windows could not be fully opened. He indicated that he was 99.9% sure that they had all been checked and were okay and he would check with the Environmental Services Department.

At 4:17 PM, the Maintenance Director provided the surveyors with a "Window Operation Assessment" document, dated May 1, 2016. This document indicated its purpose was to provide an assessment of patient care areas with operable windows and to limit the risk. It indicated that "Once the A/C has been removed if the window doesn't get secured it could be open enough for a person to exit the window." The document indicated that "The HVAC [Heating, Ventilation, and Air Conditioning] shop will have to secure windows from opening beyond 6" [inches] after an A/C has been removed in the patient care areas in Kelly and Phillips Oliver buildings". The Maintenance Director told surveyors that they check all windows. The surveyors asked when the last time the windows were checked and he indicated that he did not have any documentation as to when the windows were last checked but he did have documentation from February 2017.

At 4:35 PM, the Maintenance Director returned with a document, dated January 31, 2017, that indicated that the windows on the Phillips Oliver Unit, third floor unit, had been secured and they would not open. Surveyors asked him if there was a plan to check windows after January 31, 2017 and he stated there was no system in place to check the windows.

At 5:00 PM, a surveyor started to check all of the windows on the Phillips Oliver 3 Unit. The safety screen, located on one of the two windows in Room #394, was found to be unlocked. When the screen was swung open, the window could be fully opened and the opening was large enough for an individual to fall or jump out. Surveyors found no other windows, on inpatient units, that were not secured.

At approximately 5:10 PM, the Maintenance Director confirmed the safety screen was unlocked and the window could be fully opened. The Maintenance Director called someone to bring the key to lock the window. However, when a maintenance person arrived, none of the keys he came with would lock the window.

At 5:30 PM, three surveyors met with hospital administration staff to discuss the observations of two windows that could be fully opened on the Phillips Oliver 3 Unit in Rooms #289 and #394. It was discussed that there was a potential that an individual could fall or jump from the window and sustain serious to life threatening injuries. The surveyors requested an immediate action plan to ensure the safety of all inpatients.

At 5:30 PM, a surveyor observed that the window, in Room #394, had been secured with two screws to prevent the window from opening.

At 6:38 PM, the Vice President of Nursing, provided documentation that indicated the following: "We will be rounding every window in EMMC [Eastern Maine Medical Center] that can open in a patient care area and will make sure all are secured and safe. This will be completed by 2100 [9:00 PM] this evening".

On March 7, 2018, at 7:50 AM, two surveyors observed the area below Room #394. If an individual was to fall or jump at an angle to the left, they would hit the air handling units that were located on the roof below. If an individual was to fall or jump at an angle to the right, they would fall three stories and hit pavement on the ground.

At 8:30 AM, a surveyor again confirmed that the windows in Rooms #389 and #394 were secured and could not be opened. At this time, the Maintenance Director estimated that from the window in Room #389 there was an 18 foot drop to the rubber coated roof below and the window opening was 25 inches by 28 inches if the window was fully opened. He also estimated the drop to the roof below the window in Room #394 was about 18 feet or less and there was approximately another eight foot drop to pavement from the right of the roof.

At 11:38 AM, the hospital provided a more detailed "Corrective Action Plan for Window Security". This plan indicated the following:

- On March 6, 2018, the Vice President of Nursing and the Vice President of Support Services conducted an inspection of all inpatient care units with potentially operable windows to confirm that the windows were secure.

- There were four inpatient units (Phillips Oliver 3, Kelley 3, Clason 1 ICU, and Grant 1 CCU/CSU) that the hospital had modified the windows and they determined that these windows were all secured shut.

- "EMMC Facilities Department is further securing Phillips Oliver 3 [PO3] and Kelley 3 [K3] patient windows by fabricating and installing Unistrut metal window stops with tamper resistant screws in the vertical rails. Tamper resistant screws will be used to install the stops vertically into the window framing to secure the window. Window opening will be restricted to a vertical distance of 6 inches or less in consideration of patient comfort. All patient windows on PO3 and K3 will additionally secured in this manner by 14:00 [2:00 PM] on Wednesday 3/7/2018."

- "On a monthly basis, each secured window that has been modified by Eastern Maine Medical Center (not manufactured to open 6 inches or less) will be visually inspected for integrity by the facility maintenance department and the inspection documented in the computerized work order program."

Immediate Jeopardy is defined as "a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident." The observation of two windows on a third floor of the hospital that could be fully opened to a point that an individual could fall or jump out created a potential dangerous situation for patients; thus, a determination of immediate jeopardy was made.

On March 7, 2018, at 1:45 PM, the State Agency discussed the above situation with representatives from the Boston Regional Office of the Centers of Medicare and Medicaid Services, who agreed that the situation met the definition of immediate jeopardy.

2. On March 6, 2018, at 9:30 AM, surveyors observed that a nurse had left a set of keys on an unattended cart that contained a variety of needles in the Radiology and Oncology Clinic. This finding was confirmed, with the Executive Director, at the time of the observation.

3. March 6, 2018, at approximately 11 AM, surveyors observed two unlocked IV carts containing needles, syringes and IV supplies in alcove D and the alcove next to the "pending" room where patients wait for laboratory and test results in the Emergency Department. In an interview with the Assistant Unit Manager, she confirmed that patients and visitors were allowed to ambulate in the corridor unsupervised where these carts were located. She further confirmed that the carts were not locked but were supposed to be secured with the electronic numeric lock located on the top of each cart.

On March 9, 2018, at 2:20 PM, the same two IV carts in the same corridor alcoves were again found to be unsecured/unlocked when the surveyor returned to the unit. The Unit Manager reconfirmed that the two IV carts were not locked but were supposed to be locked.
VIOLATION: LIFE SAFETY FROM FIRE Tag No: A0709
Based on on-site observations, interviews, and document reviews conducted by Life Safety Code surveyors, the hospital was not in full compliance with 42 CFR 482.41(b), the Life Safety Code.

Please see the Life Safety violations cited on the Centers for Medicare and Medicaid Services (CMS) form 2567 dated March 7, 2018, for the Maine State Fire Marshal's Office Life Safety Code survey.