Central Maine Medical Center

“PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION CFR(s): 482.13(a)(2)(iii) At a minimum: 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. This Standard is not met as evidenced by: 50294 Based on document reviews and interviews, the hospital failed to recognize a grievance and enter into the patient complaint platform, by providing a written or verbal notice of its determination in accordance with their policy, “Patient Complaints and Grievances” last revised 11/4/2024. Findings: In accordance with the hospital policy titled, “Patient Complaints and Grievances”, on page 2 of 9, states, “Patient complaints and grievances will be entered into the patient complaint platform.” It continues to say, “A verbal patient complaint that cannot be promptly resolved by the Staff Member(s) present (or who can get there quickly) is considered a grievance and shall be referred to the Manager of the involved department in addition to being entered in the patient complaint platform.” The patient left a voice mail on June 5, 2026 for the Risk Manager stating that she found labs in her MyChart that was not hers, and the phone call was not returned. The concern was never entered into the patient complaint platform, nor considered a grievance, according to the Risk Manager on 06/18/2026 in an interview at 11:35AM. In accordance with the hospital policy on page 3 of 9, states, “Resolution: A written letter from the CMH Patient Relations Specialist shall be provided to the grievant when the manager has resolved the grievance. The written notification of the resolution will include: (1) the contact person, (2) the steps that were taken on behalf of the patient to investigate and resolve the grievance, (3) the results of the investigation and (4) the date of the grievance resolution. On average, grievances will be resolved within 7 days of receipt. If resolution will take more than 7 days, the grievant will be notified that the review is still in progress and provided an update every 30 days until resolution is reached.” The concern was never entered into the patient complaint platform, the complaint has not yet been resolved, nor was an update letter sent to the patient, as of the last day of the onsite survey, June 18, 2026.”

“PATIENT RIGHTS: CONFIDENTIALITY OF RECORDS CFR(s): 482.13(d)(1) The patient has the right to the confidentiality of his or her clinical records. This Standard is not met as evidenced by: 50294 Based on document reviews and interviews, the hospital failed to assure that medical records were accurate and kept confidential, as labs belonging to another patient were found in the complainant’s medical records. Findings: In accordance with hospital policy, “Patients’ Rights and Responsibility”, page 2 of 5, reads in part ... “To have medical records and information handled in a confidential manner among those directly involved in your care.” On 06/17/2026 at 12:40PM, during a medical record review with Director of Practice Operations, it was confirmed that laboratory results belonging to another patient being posted to the affected patient’s medical record. This created the potential for inaccurate clinical decision making and compromised the integrity of the patient’s medical record.”

“CONTENT OF RECORD: INFORMED CONSENT CFR(s): 482.24(c)(4)(v) [All records must document the following, as appropriate:] Properly executed informed consent forms for procedures and treatments specified by the medical staff, or by Federal or State law if applicable, to require written patient consent. This Standard is not met as evidenced by: 50294 Based on document reviews and interviews, the hospital failed to ensure that copies of consent documents were available for patients to review prior to patients signing on an electronic signature pad that they had reviewed the unavailable consent documents in one (1) out of one (1) registration areas observed. Findings: 1. Document reviews and interviews revealed that registration documents were not available for the patient’s review. 2. Interviews revealed that the “Patient Information Guide” was not readily available and after multiple requests into the second day of the survey, was the guide produced. 3. Interviews with patient account representative, and the outpatient lab supervisor verified staff were not aware and trained to the full registration packets, specifically “Patient Information Guide” which as named in the complaint.”

“PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION CFR(s): 482.13(b)(4) The patient has the right to have a family member or representative of his or her choice and his or her own physician notified promptly of his or her admission to the hospital. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to provide evidence that patients were offered to have the patient’s Primary Care Physician notified of an admission to the hospital for one (1) of ten (10) patients reviewed (Patient #3). Findings: The hospitals policy “Physician and Family Notification Upon Admission”, approved 07/29/2024 states in part, “The Patient Access Specialist must also ask the patient whether the hospital should notify his/her own physician. If the patient requests either notifications the Patient Access Specialist must provide such notice promptly to the designated physician ... . The Patient Access Specialist must document whether the patient wanted a family member/representative notified, the date, time and method of notification or whether the patient declined. If the patient was incapacitated at the time of admission the medical record must indicate what steps were taken to provide notice to the family member/representative and to the patient’s physician.”. On 02/25/2026 from 9:26 AM to 10:30 AM, ten (10) patient records were reviewed with the Senior Director of Nursing. This review indicated the following in Patient #3’s medical record: - Patient #3 had no documented evidence that they were asked by a Patient Access Specialist about their right to have the Primary Care Physician notified; and - Patient #3 had no documented evidence that the Primary Care Physician was notified of their admission. On 02/25/2026 from 9:26 AM to 10:30 AM, the Senior Director of Nursing confirmed the finding at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(2) Restraint or seclusion may only be used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the hospital’s policy for restraints and seclusion, related to the documenting of less restrictive measures tried before applying restraints, was implemented for one (1) of five (5) restrained patients (Patient #13). Findings: The hospitals “Restraint and Seclusion” policy, last approved 02/13/2025, states in part, “Restraint or seclusion may be used when it can be clinically justified and less restrictive means are not sufficient to protect the physical safety of patients, team members or others ... The decision to use restraint or seclusion is not driven by diagnosis, but by a comprehensive individual patient assessment. For a given patient at a particular point in time, this comprehensive individualized patient assessment is used to determine whether the use of less restrictive measures poses a greater risk than the risk of using restraint or seclusion. The comprehensive assessment should include a physical assessment to identify medical problems that may be causing behavior changes in the patient. ... Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms.” On 02/25/2026 from 12:06 PM to 12:47 PM, five (5) patients’ medical records that were restrained were reviewed with the Senior Director of Nursing. This review indicated the following in Patient #13’s medical record: - On 11/10/2025 at 4:43 PM, Medical Doctor #1 ordered (non-violent) soft wrist restraints; - On 11/10/2025 at 7:00 PM, Registered Nurse (“RN”) #1 provided the first documentation of a restraint reassessment, which did not include less restrictive measures that were attempted, as that would be documented when the restraints were applied; - On 11/11/2025 at 10:29 AM, RN #2 documented that Patient #13 was appropriate for restraint removal and discontinued the restraint at that time; and - There was no documentation in the medical record that less restrictive measures were attempted prior to applying the restraints. On 02/25/2026 from 12:06 PM to 12:47 PM, the above findings were confirmed at the time of the review by the Senior Director of Nursing.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(3) The type or technique of restraint or seclusion used must be the least restrictive intervention that will be effective to protect the patient or others from harm. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the hospital’s policy for restraints, related to the documenting of the type of restraint ordered, was implemented for one (1) of five (5) restrained patients (Patient #13). Findings: The hospital’s “Restraint and Seclusion” policy, last approved 02/13/2025, states in part, “Restraint or seclusion may be used when it can be clinically justified and less restrictive means are not sufficient to protect the physical safety of patients, team members or others ... The decision to use restraint or seclusion is not driven by diagnosis, but by a comprehensive individual patient assessment. Examples for Restraint or Seclusion Alternatives: The purpose is to provide tools for the nursing team on suggestions for alternatives and as a reminder to use the least restrictive restraints. ... Alternative to restraint or seclusion use: should always be attempted and documented before placing in a restraint or seclusion.” On 02/25/2026 from 12:06 PM to 12:47 PM, five (5) patients’ medical records that were restrained were reviewed with the Senior Director of Nursing. This review indicated the following in Patient #13’s medical record: - On 11/10/2025 at 4:43 PM, Medical Doctor #1 ordered soft wrist (non-violent) restraints; - On 11/11/2025 at 10:29 AM, RN #2 documented that Patient #13 was appropriate for restraint removal and discontinued the restraint at that time; - There was no documentation to identify when the restraint was applied; - There was no documentation in the medical record that identified the alternate measures that were attempted and unsuccessful prior to placing Patient #13 in restraints. On 02/25/2026 from 12:06 PM to 12:47 PM, the above findings were confirmed at the time of the review by the Senior Director of Nursing.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored in accordance with hospital policy for one (1) of six (6) patients reviewed (Patient #13). Findings: The hospital’s “Restraint and Seclusion” policy, last approved 02/13/2025, states in part, “... Assessments by a RN shall occur as often as indicated by the patient’s condition/ behavior and at least every two (2) hours ... “. On 02/25/2026 from 12:06 PM to 12:47 PM, five (5) patients’ medical records that were restrained were reviewed with the Senior Director of Nursing. This review indicated the following in Patient #13’s medical record: - On 11/10/2025 at 4:43 PM, Medical Doctor (“MD”) #1 ordered soft wrist (non-violent) restraints; - On 11/10/2025 at 4:43 PM, MD #2 ordered Restraint Monitoring, and the order details stated “Routine, q2Hrs, for 24 HR, Assessment includes observation, nutrition/hydration, toileting, mental status, comfort, CSM check + removal of 1 restraint at a time for ROM. Restraints may be discontinued at RNs discretion post an assessment. Order Comment: Restraint monitoring will occur q2hrs while in restraint”; - On 11/10/2025 at 7:00 PM, RN #1 provided the first documentation of a restraint reassessment; - There was no documentation by an RN of when the restraints were applied; and - Per the documentation, Patient #13 was provided no restraint monitoring for the initial two (2) hours and seventeen (17) minutes. On 02/25/2026 from 12:06 PM to 12:47 PM, the above findings were confirmed at the time of the review by the Senior Director of Nursing.”

“DISCHARGE PLANNING-D/C PLANNING LIST CFR(s): [The hospital must] include the discharge planning a list of HHA’s, SNF’s, IRF’s, or LTCH’s that are available to the patient, that are participating in the Medicare program, and that serve the geographic area(as defined by the HHA) in which the patient resides, or in the case of a SNF, IRF, or LTCH, in the geographic area requested by the patient. HHAs must request to be listed by the hospital as available. (i) The list must only be presented to patients for whom home health care post hospital extended care services, SNF, IRF, or LTCH services are indicated and appropriate as determined by the discharge planning evaluation. (ii) For patients enrolled in managed care organizations, the hospital must make the patient aware of the need to verify with their managed care organization which practitioners, providers or certified suppliers are in the network of the patient’s managed care organization, it must share this with the patient or the patient’s representative. (iii) [The hospital must] document in the patient’s medical record that the list was presented to the patient or to the patient’s representative.…. This Standard is not met as evidenced by: 49750 Based on policy and procedure reviews, medical record reviews and staff interviews it was determined the hospital failed to disclose and identify home health agencies or skilled nursing facilities for which the hospital has a disclosable financial interest. Findings: A review of medical records and staff interviews revealed the hospital failed to disclose and identify home health agencies and skilled nursing facilities for which the hospital has a disclosable financial interest for four (4) of four (4) patient’s who were referred for home health services or skilled nursing services. (Pt. #1, Pt. #4, Pt. #6, and Pt. #10) This deficient practice had the potential to negatively impact all patients referred for home health services or skilled nursing services. An interview was conducted on 2/25/2026 at 2:45 PM with the System Director of Quality confirmed the facility was not aware of this regulation and that there was no such documentation or list.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 46424 Based on document review and interviews, the hospital failed to complete background checks before the first day of employment for two (2) of ten (10) new hire records reviewed. Findings: During the review of new hire records on 12/9/2025 and 12/10/2025, the background check for CNA #1 who started work on 12/1/2025 was not completed until 12/4/2025. The background check for CNA #2 who started work on 12/1/2025 was not completed with until 12/4/2025. This was confirmed by the HR Operations Specialist at the time of the finding. On 12/10/2025 at 9:20 AM, the Senior Vice President & General Counsel confirmed that the background check needs to be completed before the start of work.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 30938 Based on document review of one (1) out of ten (10) patient medical records (Pt. #6) demonstrated the Emergency Department (ED) clinical staff failed to follow the clinical policy for pain management and provide pain management for patient #6 in a timely manner. Findings: The hospital’s policy “Pain Management Policy,” last updated July 12, 2023, states in part ... “Emergency Department A. Patients will be screened for pain. If the patient reports pain, an assessment is done consistent with the scope of care, treatment and services, and the patient’s medical condition. B. If a pain problem is ongoing and not associated with the presenting problem ... C. Pain treatment may include pharmacologic and non-pharmacologic approaches. D. Pain is reassessed after pharmacologic interventions once sufficient time has elapsed for the treatment to reach peak effect. E. Pain management is included in the discharge evaluation as appropriate for the visit.” Review of Patient #6’s medical record dated October 2-3, 2024, indicated the following: * Patient #6 arrived at the Emergency Department (ED) at approximately 8:54 PM on October 2, 2024. * The triage assessment completed on October 2, 2024, at approximately 9:17 PM indicated patient #6’s pain level at that time was “8” on a 1-10 numeric pain scale. This information was entered into Patient #6’s medical record on October 2, 2024, beginning at 9:00 PM. * The Pain Management Policy defines Severe Pain as “Generally, a pain score that is within the benchmark range of 7-10/10, unless the patient identifies it as otherwise.” * On 10/02/2024 at11:04 PM, entry made indicating a reassessment of the patient was completed. This reassessment addressed the following: oxygen saturation, Glasgow Coma Score, skin color, level of consciousness (LOC), respiratory effort and pulse. No indication pain level was reassessed for changes although patient LOC was reported as alert. * A medication order for Lorazepam (antianxiety medication) and Fentanyl (pain medication) was entered at 12:17 AM on October 3, 2024, and administered at approximately 12:59 AM, which is approximately 4 hours after the determination of “Severe Pain”. * Patient #6 was not seen by a Licensed Independent Practitioner until October 3, 2024, at 12:19 AM approximately 3 hours and 20 minutes after it was determined patient #6 was experiencing “severe pain”. The physician note completed on October 3, 2024 at 3:48 AM, indicated the patient’s pain at that time was “moderate” and reported; “[Patient #6] was given fentanyl and Ativan with improvement”. Regarding the medications administered at 12:59 AM. This information was verified by email on 01/22/2025 at 8:13 AM by the hospital’s Patient Safety Program Manager.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for two (2) of ten (10) patients (Patient 2R and 9R). Findings: The hospitals “Restraint and Seclusion” policy last reviewed 5/13/2024, states in part ... “7. Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms. 8. Discontinuation: a. Restraint or seclusion shall be discontinued by the RN as soon as is safely possible once the behaviors or situations that prompted the use of restraint or seclusion are no longer evident. b. Restraint shall be discontinued by the RN as soon as is safely possible when it is determined that less restrictive means will be effective in protecting the patient/others ... .” On 7/17/2024 from 12:35 PM to 1:49 PM, ten (10) patients’ medical records that were restrained were reviewed with the Safety Program Manager. 1. Documentation in Patient 2R’s record indicated that: - On 4/11/2024 at 9:27 AM, Provider #1 ordered soft wrist restraints; - On 4/11/2024 at 10:00 AM, Registered Nurse (“RN”) #1 applied soft bilateral wrist restraints; - On 4/11/2024 3:00 PM, which was the last documented evidence of the restraint stated that the wrist restraints were released and reapplied; and therefore, - It could not be determined if the restraint was discontinued at the earliest possible time. 2. Documentation in Patient 9R’s record indicated that: - On 10/21/2023 at 12:08 PM, RN #2 applied a soft restraint to the left wrist; - On 10/21/2023 at 2:00 PM, RN #2 reassessed and reapplied the soft restraint to the left wrist; - There was no nursing documentation regarding the removal of the soft wrist restraint; and therefore, - It could not be determined if the restraint was discontinued at the earliest possible time. On 7/17/2024, the above findings were confirmed at the time of the review by the Safety Program Manager.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for one (1) of ten (10) patients that were restrained (Patient 4R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last reviewed 5/13/2024 states, in part, “A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint....”. On 7/17/2024 from 12:35 PM to 1:49 PM, ten (10) records were reviewed with the Patient Safety Program Manager. 1. Documentation in Patient 4R’s record indicated that: - On 6/03/2024 at 2:20 AM, Patient 4R required four (4) point restraints; - On 6/03/2024 at 2:27 AM, Patient 4R required chemical restraints; - On 6/03/2024 at 3:04 AM, Patient 4R required additional chemical restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. On 7/17/2024, the above findings were confirmed at the time of the review by the Safety Program Manager.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for one (1) of ten (10) patients that were restrained (Patient 4R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last reviewed 5/13/2024 states, in part, “A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint ... Face-to-face assessment should include: · The patient’s immediate situation · The patient’s reaction to the intervention · The patient’s medical and behavioral condition · The need to continue or terminate the restraint or seclusion.” In addition, it states, “Chemical restraints/drug used for restraints may be used for the safety of patients or others and to help the patient more effectively interact with their environment when less restrictive interventions are ineffective. Chemical/drug restraints may not be used for staff convenience. Documentation should include a description of the patient’s behavior supporting the use of the medication and the patient’s response to the medication. Medications used as a chemical/drug restraint are ordered as a one-time dose.” On 7/17/2024 from 12:35 PM to 1:49 PM, ten (10) records were reviewed with the Patient Safety Program Manager. 1. Documentation in Patient 4R’s record indicated that: - On 6/03/2024 at 2:20 AM, Patient 4R required four (4) point restraints; - On 6/03/2024 at 2:27 AM, Patient 4R required chemical restraints; - On 6/03/2024 at 3:04 AM, Patient 4R required additional chemical restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraints being initiated that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraints. On 7/17/2024, the above findings were confirmed at the time of the review by the Safety Program Manager.”

“EMERGENCY SERVICES POLICIES CFR(s): 482.55(a)(3) [If emergency services are provided at the hospital --] (3) The policies and procedures governing medical care provided in the emergency service or department are established by and are a continuing responsibility of the medical staff. This Standard is not met as evidenced by: 46424 Based on document review and interviews, three (3) out of three (3) patient medical records demonstrated the Emergency Department (ED) clinical staff failed to follow the clinical policy for blood administration. Findings: The hospital’s policy “Administration of Blood Components,” last updated December 29, 2022, states in part ... “Consent or refusal of blood products will be documented on form 443464 CMMC Consent-Refusal Non-Emergency Blood Transfusions ...” - A copy of the consent was not found during chart review for the medical record of Patient #3. This was confirmed by the ED Nurse Lead and the ED Nurse Director at 9:57 on 5/16/2024. The hospital’s policy “Administration of Blood Components,” last updated December 29, 2022, states in part ... “Document vital signs at the following intervals ...” - A medical record review of three (3) out of three (3) patients who received blood products in the ED was conducted. The medical records of Patients #2, #3, and #4 failed to contain documentation that vital signs were completed per hospital policy. This was confirmed by ED Nurse Lead and ED Nurse Director at 10:30 on 5/16/2024.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the type of restraint that was ordered was the type of restraint used for 2 (two) of 5 (five) patients reviewed (Patient 1R and Patient 4R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “Restraints will be safely applied and removed, and patients will be monitored and reassessed by qualified staff as outlined within this policy ... Initiation: Each episode of restraint or seclusion shall be initiated: a. Upon the order of a provider who is responsible for the patient. At CMH [Central Maine Healthcare] Providers who may write orders for a restraint include Physician, Nurse Practitioner, Physician Assistants and Midwife. b. By a trained RN when he or she determines it is necessary to protect the patient, staff member or others. An order from a provider who is responsible for the patient shall be obtained as soon as possible after such initiation ...”. On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following: 1. Documentation in Patient 1R’s record indicated the following: - On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints; - On 07/23/2023 at 4:20 PM, nursing documentation indicated that four (4) point hard restraints were applied; and - On 07/23/2023 at 5:07 PM, Patient 1R’s Provider ordered a four (4) point soft restraint. 2. Documentation in Patient 4R’s record indicated the following: - On 09/05/2023 at 4:21 PM, Patient 6R required four (4) point restraints; - On 09/05/2023 at 4:21 PM, nursing documentation indicated that four (4) point hard restraints were applied; and - On 07/23/2023 at 7:18 PM, Patient 4R’s Provider ordered a four (4) point soft restraint. Based on the above, the patients were not restrained with the type of restraint that was ordered by the physician as four (4) point soft restraints were ordered and four (4) point hard restraints were used. On 01/23/2024, the above findings were confirmed with the Patient Safety Program Manager at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for two (2) of five (5) patients that were restrained (Patient 1R and 4R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint....”. On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following: 1. Documentation in Patient 1R’s record indicated the following: - On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. 2. Documentation in Patient 4R’s record indicated the following: - On 09/05/2023 at 5:30 PM, Patient 4R required a physical hold for a chemical restraint; - On 09/05/2023 at 4:21 PM, Patient 4R required four (4) point restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. On 1/23/2024, the Patient Safety Program Manager confirmed the above findings at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for two (2) of five (5) patients that were restrained (Patient 1R and 4R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 5/26/2023 states, in part, Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... “. On 01/23/2024 at 2:00 PM, five (5) records were reviewed with the Patient Safety Program Manager. This review revealed the following: 1. Documentation in Patient 1R’s record indicated the following: - On 07/23/2023 from 4:20 PM through 5:07 PM, Patient 1R required four (4) point restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint. 2. Documentation in Patient 4R’s record indicated the following: - On 09/05/2023 at 5:30 PM, Patient 4R required a physical hold for a chemical restraint; - On 09/05/2023 at 4:21 PM, Patient 4R required four (4) point restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint. On 1/23/2024, the Patient Safety Program Manager confirmed the above findings at the time of the review.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 46424 Based on document reviews and interviews, the hospital failed to ensure that one (1) of ten (10) patients were free from abuse and/or neglect (Patient #1). Findings: The hospital’s “Suspected Patient Abuse or Neglect by a Team Member” policy, last revised 7/21/2023, states in part, defines abuse as “The infliction of injury, unreasonable confinement, intimidation or cruel punishment that causes or is likely to cause physical harm or pain or mental anguish; sexual abuse or sexual exploitation; financial exploitation; or the intentional, knowing or reckless deprivation of essential needs. “Abuse” includes acts and omissions; An employee suspected of, or whom an allegation of abuse is made, will be immediately removed from patient care and placed on suspension, or leave of absence as appropriate, pending further investigation; and If any Mandated Reporter of the CMH Healthcare System knows or has reasonable cause to suspect that an incapacitated or dependent adult has been or is at substantial risk of abuse, neglect or exploitation, s/he shall immediately report the same, via telephone, to the Maine Department of Health and Human Services”. On 11/20/2023 at approximately 1:00 PM, Patient #1’s medical record was reviewed. This revealed the following: - On 11/3/2023 at 5:30 PM, Patient #1 arrived via ambulance to the Emergency Department (“ED”) with a chief complaint of throat and abdominal pain after swallowing batteries; - On 11/3/2023 at 7:35 PM, Registered Nurse (“RN”) #1 documented that, “[Patient #1] had become violent and was kicking, hitting, biting, and spitting on staff members. [Patient #1] attempted to bite and scratch this RN multiple times. With numerous security staff and nursing staff, [Patient #1] was moved to a bed and placed into 4 point restraints”; - On 11/3/2023 at 7:38 PM, a provider documented that Patient #1 was violent toward self and staff and was not able to be verbally redirected. Patient #1 was administered a chemical restraint and was then placed in four (4) point restraints; and - On 11/4/2023 at 9:42 AM, Patient #1 was discharged from the ED. On 11/20/2023 at 3:30 PM, an interview was conducted with the ED Nurse Director. She stated the following: - [Security Officer #1] sent an email to me on Friday 11/3/2023 at 11:30 PM to let me know that he witnessed a nurse slap [Patient #1] in the face after the patient spit on the nurse while performing a restraint; - I did not read the email until the evening of 11/5/2023, and I then informed the RN covering for me that week, as I was going on vacation; - On 11/6/2023, security entered an incident report; - During the week of 11/6/2023, the hospital had meetings to discuss this incident, and RN #1 was terminated; - On 11/13/2023, I submitted a report to Adult Protective Services; and - The hospital policy is “not clear for front line staff”. On 11/21/2023 at 1:12 PM, an interview was conducted with Security Officer #1. He recalled that he was a part of the security team that assisted the RN staff in the ED with Patient #1. He stated the following: - I watched [RN #1] assault [Patient #1]. He slapped him/her across the face. I told him he can’t be doing that; - Two (2) of my officers saw it and said something, but no one else in the room made comments; - I should have notified the nursing supervisor or my supervisor. I just notified the ED Nurse Director that night at 11:30 PM by email; and - When asked if he would consider it abuse, he stated, “Yes, absolutely 100%.” On 11/21/2023 at 9:24 AM, an interview was conducted with the Director of Risk Management and the Clinical Risk Manager. When asked what is expected of staff when witnessing or suspecting abuse or neglect, the Director of Risk Management responded, “Make sure the patient is safe” and “Take the employee out of the mix.” On 11/21/2023 at 10:30 AM, RN #1’s time card was reviewed and revealed the following: - On 11/3/2023, RN #1 continued to work, after being witnessed to slap Patient #1, until the end of the shift, until 10:08 PM; - On 11/4/2023, RN #1 worked a full shift from 9:38 AM to 10:11 PM; - On 11/5/2023, RN #1 worked a full shift from 9:38 AM to 10:08 PM; and - On 11/7/2023, the hospital terminated the employment contract with RN #1. On 11/21/2023 at 9:24 AM, The Clinical Risk Manager confirmed that when leadership reviewed the incident on 11/6/2023, the ED Nurse Director did not have information related to RN #1 in the report. However, as they started to investigate, security shared the information related to RN #1 slapping Patient #1. The allegation of abuse was not reported to the Department of Health and Human Services until 11/13/2023, a duration of ten (10) days after the incident. The Clinical Risk Manager further stated, “We have had some delay in the immediate reporting, and I am doing education on the mandated reporter. Typically, the ones [reports] that I have seen, it has not been immediate.””

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(5) §§482.13(e)(5) - The use of restraint or seclusion must be in accordance with the order of a physician or other licensed practitioner who is responsible for the care of the patient and authorized to order restraint or seclusion by hospital policy in accordance with State law. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure a physician’s order was obtained for two (2) of six (6) patients that were restrained (Patient 2R and 6R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “Initiation: Each episode of restraint or seclusion shall be initiated: a. Upon the order of a provider who is responsible for the patient. At CMH [Central Maine Health] Providers who may write orders for a restraint include Physician, Nurse Practitioner, Physician Assistants and Midwife. b. By a trained RN when he or she determines it is necessary to protect the patient, staff member or others. An order from a provider who is responsible for the patient shall be obtained as soon as possible after such initiation ... “. On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following: 1. Documentation in Patient 2R’s record indicated the following: - On 11/03/2023 at 7:37 PM, Patient 2R required four (4) point restraints; - The restraint was discontinued at 8:35 PM; and - There was no evidence in the medical record of a Provider order for four (4) point restraints. 2. Documentation in Patient 6R’s record indicated the following: - On 11/20/2023 at 6:05 PM, Patient 6R required four (4) point restraints; - The restraint was discontinued at 6:25 PM; and - There was no evidence in the medical record of a Provider order for four (4) point restraints. On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above findings at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(9) Restraint or seclusion must be discontinued at the earliest possible time, regardless of the length of time identified in the order. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure a restraint was discontinued at the earliest time possible for one (1) of six (6) patients (Patient 5R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... Discontinuation: a. Restraint or seclusion shall be discontinued by the RN as soon as is safely possible once the behaviors or situations that prompted the use of restraint or seclusion are no longer evident b. Restraint shall be discontinued by the RN as soon as is safely possible when it is determined that less restrictive means will be effective in protecting the patient/others”. On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following: 1. Documentation in Patient 5R’s record indicated the following: - Nursing staff documented that on 11/06/2023 at 5:55 PM, Patient 5R had soft bilateral mitt restraints applied; and - There was no nursing documentation regarding the removal of the soft bilateral mitt restraints; and therefore, - It could not be determined if the restraint was discontinued at the earliest possible time. On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(10) The condition of the patient who is restrained or secluded must be monitored by a physician, other licensed practitioner or trained staff that have completed the training criteria specified in paragraph (f) of this section at an interval determined by hospital policy. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the condition of a patient, who was in restraints, was monitored in accordance with hospital policy for one (1) of six (6) patients reviewed (Patient 5R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “ ... Assessments by a RN shall occur as often as indicated by the patient’s condition/ behavior and at least every two (2) hours ... “. On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following: 1. Documentation in Patient 5R’s record indicated the following: - Nursing staff documented that on 11/06/2023 at 5:55 PM, Patient 5R had soft bilateral mitts applied; - On 11/6/2023 at 5:55, the doctor wrote an order for Patient 5R to have, in part, “Restraint monitoring will occur [every] 2 [hours] while in restraint”; and - There was no documented evidence of the required monitoring while in restraints. On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) When restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, the patient must be seen face-to-face within 1-hour after the initiation of the intervention -- o By a-- - Physician or other licensed practitioner; or - Registered nurse who has been trained in accordance with the requirements specified in paragraph (f) of this section. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure the patient received a face-to-face evaluation by the provider within one (1) hour of initiating a restraint for three (3) of six (6) patients that were restrained (Patient 1R, 2R and 6R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “A responsible physician, trained NP [Nurse Practitioner], PA [Physician Assistant] or Midwife shall perform a face-to-face assessment of the patient’s physical and psychological status within 1 hour of the initiation of restraint....”. On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following: 1. Documentation in Patient 1R’s record indicated the following: - On 08/13/2023 at 3:30 PM, Patient 1R required a physical hold for a chemical restraint; - On 08/13/2023 at 4:30 PM, Patient 1R required four (4) point restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. 2. Documentation in Patient 2R’s record indicated the following: - On 11/03/2023 from 7:10 PM to 8:35 PM, Patient 2R required four (4) point restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. 3. Documentation in Patient 6R’s record indicated the following: - On 11/03/2023 at 5:45 PM, Patient 6R required a physical hold for a chemical restraint; - On 11/03/2023 at 6:05 PM, Patient 6R required four (4) point restraints; and - There was no documented evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation. On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above findings at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(12) [the patient must be seen face-to-face within 1 hour after the initiation of the intervention -- ] §482.13(e)(12)(ii)To evaluate - 1. The patient’s immediate situation; 2. The patient’s reaction to the intervention; 3. The patient’s medical and behavioral condition; and 4. The need to continue or terminate the restraint or seclusion. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure that restrained patients received an evaluation within one (1) hour of restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint for three (3) of six (6) patients that were restrained (Patient 1R, 2R and 6R). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 5/26/2023 states, in part, Documentation of Assessment/Monitoring: a. Episodes of restraint or seclusion shall be documented as indicated on currently approved assessments, monitoring and ordering forms ... “. On 11/20/2023 at 1:01 PM, six (6) records were reviewed with the Clinical Quality Review Coordinator. This review revealed the following: 1. Documentation in Patient 1R’s record indicated the following: - On 08/13/2023 at 3:30 PM, Patient 1R required a physical hold for a chemical restraint; - On 08/13/2023 at 4:30 PM, Patient 1R required four (4) point restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint. 2. Documentation in Patient 2R’s record indicated the following: - On 11/03/2023 from 7:10 PM to 8:35 PM, Patient 2R required four (4) point restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint. 3. Documentation in Patient 6R’s record indicated the following: - On 11/03/2023 at 5:45 PM, Patient 6R required a physical hold for a chemical restraint; - On 11/03/2023 at 6:05 PM, Patient 6R required four (4) point restraints; and - There was no evidence of a face-to-face evaluation by a provider within one (1) hour of the restraint initiation that documented the patient’s immediate situation, reaction to the intervention, medical and behavioral condition and the need to continue or terminate the restraint. On 11/20/2023, the Clinical Quality Review Coordinator confirmed the above finding at the time of the review.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(f)(4) Training documentation. The hospital must document in the staff personnel records that the training and demonstration of competency were successfully completed. This Standard is not met as evidenced by: 42601 Based on document reviews and interviews, the hospital failed to ensure staff completed restraint training according to hospital policy and the documentation of the training was contained in the staff member’s personnel record for four (4) of 10 (ten) staff who had been involved in a patient restraint (Registered Nurse #2, Medical Doctor #1, #2, and #3). Findings: Central Maine Medical Center’s “Restraint and Seclusion” policy, last approved 05/26/2023 states, in part, “Training Plan: Hospital and Medical staff members shall receive training in the following subjects as it related to assigned duties performed under this policy regarding the use of restraints during the orientation process. Such training shall take place before the new staff member is asked to implement the provisions of this policy and shall be repeated periodically, based on the results of quality monitoring activities. Medical staff members will receive additional education every two years as part of their re-credentialing process and hospital staff will receive additional education annually. a. Providers who order restrain shall be trained in the requirements of this policy. b. Hospital staff members who assess patients for restraint or who apply restraint shall receive the training in the following: i. Techniques to identify staff and patient behaviors, events and environmental factors that may trigger circumstances that require the use of restraint. ii. The use of non-physical intervention skills. iii. Choosing the least restrictive intervention based on individualized assessment of the patient’s medical or behavioral status or condition. iv. The safe application and use of all types of restraints by the staff member, including training in how to recognize and respond to physical and psychological distress (for example; positional asphyxia). v. Clinical identification of specific behavior changes that indicate that a restraint is no longer necessary. vi. Monitoring the physical and psychological well-being of the patient who is restrained including but not limited to; respiratory and circulatory status, skin integrity and vital signs. vii. The use of first aid techniques & cardiopulmonary resuscitation”. 1. Documentation in Patient #5R’s record indicated the patient was placed in restraints on 11/06/2023 and Registered Nurse (“RN”) #1 was involved with the patient and the restraint. There was no evidence provided by the hospital to indicate RN #1 had completed training on restraints since 12/26/2021. 2. Documentation in Patient #6R’s record indicated the patient was placed in restraints on 11/03/2023 and Medical Doctor (“MD”) #1 was involved in the care of the following patient who was restrained. There was no evidence provided by the hospital to indicate MD #1 had completed training on restraints. 3. Documentation in Patient #5R’s record indicated the patient was placed in restraints on 11/06/2023 and MD #2 was involved in the care of the following patient who was restrained. There was no evidence provided by the hospital to indicate MD #2 had completed training on restraints. 4. Documentation in Patient #1R’s record indicated the patient was placed in restraints on 08/13/2023 and MD #3 was involved in the care of the following patient who was restrained. There was no evidence provided by the hospital to indicate MD #3 had completed training on restraints. On 11/21/2023 at 2:36 PM, the Quality Accreditation Program Manager confirmed no evidence could be provided that indicated RN #1 and MD #1, MD #2, and MD #3 had completed the required hospital policy training on restraints.”