Northern Light Eastern Maine Medical Center

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(1)(ii) Seclusion is the involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion may only be used for the management of violent or self-destructive behavior. This Standard is not met as evidenced by: 09447 Based on review of a video, document review and interviews, it was determined the facility failed to obtain a provider order for locked door seclusion before placing a patient in a room that was locked with the patient inside, thus creating involuntary confinement of the patient who did not display violent or self-destructive behavior. For one (1) of ten (10) patient records reviewed. (Patient #1) Findings: On May 5, 2026, at 12:47 AM, the surveyor went to the Emergency Department to observe 2 (two) Consultation Rooms and the Overflow Area. Both Consultation rooms locked and had cameras. A keypad was used to unlock the door of Consultation Room #1, by Employee #1. This was the room Patient #1 occupied on May 12, 2026. On May 6, 2026, at approximately 11:37 AM. a video of Patient #1’s stay in the Emergency Department on 3/12/2026 was reviewed. This video documented a demonstration of how Patient #1 could summon assistance if he/she needed it, as evidenced by Employee #2 waving at the camera to demonstrate. On May 6, 2026, at approximately 12:08 PM, an interview was conducted with Employee #2. He/she stated that he/she remembered the patient hit the Emergency button in the consultation Room several times. He/she stated that Patient #1 kept saying that they wanted to leave and was tired of waiting. The medical record note by nursing staff indicated Patient #1 was in the “Consult Room” (with door locked) at 10:10 PM on 03/12/2026. A flow sheet entry by the same nurse indicated the patient was still in the “Consult Room” at 11:00 PM on 03/12/2026. Resulting in evidence that Patient #1 was in a locked room for a minimum of fifty (50) minutes, with no provider order for “locked Door Seclusion”. On May 7, 2026, at 12 noon, Patient #1’s medical record was reviewed. The record failed to contain any orders for seclusion for Patient #1.”

“PATIENT RIGHTS: RESTRAINT OR SECLUSION CFR(s): 482.13(e)(11) Physician and other licensed independent practitioner training requirements must be specified in hospital policy. At a minimum, physicians and other licensed practitioners authorized to order restraint or seclusion by hospital policy in accordance with State law must have a working knowledge of hospital policy regarding the use of restraint or seclusion. This Standard is not met as evidenced by: 48232 Based on document reviews and interviews, the hospital failed to ensure a provider completed mandatory restraint training prior to ordering patients be placed in restraints for one (1) out of six (6) provider training records reviewed (Physician Assistant #1). Northern Light Eastern Maine Medical Center’s Policy titled, “Restraint and Seclusion,” last revised 09/19/2023 states in part: “...All staff having direct patient contact with a patient in restraint will receive education and training upon hire and annually... Physicians and other AHPs will be provided education in order to maintain a working knowledge of this policy and appropriate order sets...” Patient #14’s medical record revealed that Physician Assistant #1 ordered Bilateral Mitts, a Non-Behavioral Restraint, on 03/26/2025 at 9:41 AM. On 04/23/2025 at 8:59 AM, the surveyor requested evidence that Physician Assistant #1 had completed their mandatory restraint training. On 04/23/2025 at 1:32 PM, the Regulatory and Licensing Compliance Officer confirmed that Physician Assistant #1 had not completed their mandatory restraint training until 04/23/2025, one (1) day after the date of the initiation of the survey. The Regulatory and Compliance Officer confirmed on 04/23/2025 at 1:32 PM that the mandatory restraint training course Physician Assistant #1 had not completed was titled, “SQ Acute: Restraint and Seclusion (PA).” The Regulatory and Compliance Officer confirmed that when Physician Assistant #1 ordered restraints for Patient #12 on 03/26/2025 they did not have their mandatory restraint training completed.”

“STABILIZING TREATMENT CFR(s): 489.24(d)(1-3) (1) General. Subject to the provisions of paragraph (d)(2) of this section, if any individual (whether or not eligible for Medicare benefits) comes to a hospital and the hospital determines that the individual has an emergency medical condition, the hospital must provide either- (i) within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition. (ii) For for transfer of the individual to another medical facility in accordance with paragraph (e) of this section. (2) Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual (ii) This section is not applicable to an inpatient who was admitted for elective (nonemergency) diagnosis or treatment. (iii) A hospital is required by the conditions of participation for hospitals under Part 482 of this chapter to provide care to its inpatients in accordance with those conditions of participation. (3) Refusal to consent to treatment. A hospital meets the requirements of paragraph (d)(1)(i) of this section with respect to an individual if the hospital offers the individual the further medical examination and treatment described in that paragraph and informs the individual (or a person acting on the individual’s behalf) of the risks and benefits to the individual of the examination and treatment, but the individual (or a person acting on the individual’s behalf) does not consent to the examination or treatment. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. The hospital must take all reasonable steps to secure the individual’s written informed refusal (or that of the person acting on his or her behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. This Standard is not met as evidenced by: 45336 Finding: Based on observations, record reviews, and interviews, the facility failed to provide a medical screening examination with the capability of the hospital’s Emergency Department (“ED”) for a patient who came to the ED seeking care in one (1) of twenty-one (21) ED patient records reviewed (Patient #1). The hospital’s “Emergency Management and Transfer Rule” policy, last revised 04/01/2024, states in part, “ ...If an Individual comes to the Emergency Department, then the hospital must provide a Medical Screening Examination...” On 05/10/2024, Northern Light Eastern Maine Medical Center self-reported a possible EMTALA violation stating, in part, “[Patient #1] presented to Eastern Maine Medical Center’s ED on Friday, May 10, 2024, at approximately 8:30 PM, and felt he/she had been turned away by ED staff due to having his/her infant with him/her.” On 05/21/2024, at 11:06 AM, the Regulatory and Licensing Compliance Officer provided a summary of the hospital’s investigation of Patient #1’s allegations. The summary states in part, “On May 13, 2024, [Manager of Patient Access], Manager of Patient Access, interviewed [Registration Representative], Registration Representative, who was present when the patient [Patient #1] arrived at the ED. I [Manager of Patient Access] spoke with the Registration employee on 05/13/24 to take her statement on the conversation between the patient and the Pivot nurse [Nurse #1]. Per the Registration employee, the Pivot nurse [Nurse #1] asked, “is that your baby?”. The patient said, “yes.” The nurse then said “then you’ll need to find someone to take your baby”. The patient, with a puzzled look, said “okay”, and then turned around and left. The patient was not registered prior to leaving. Per [Registration Representative], the Pivot nurse never asked the patient what he/she needed to be seen for.” On 05/21/2024, at 11:13AM, the Emergency Department Nurse Manager stated, “[Patient #1] never received a medical screening exam, after he/she presented on May 10.” Northern Light Eastern Maine Medical Center identified the potential violation, self-reported the event, and put in measures to ensure staff did not pose questions that could possibly deter a patient in the future from seeking care. Such measures included a review of the facility’s Emergency Medical Treatment and Active Labor Act (“EMTALA”) policies, mandatory online training, and in-person training for Emergency Department and Registration staff. At the time of the on-site survey, surveyors determined, through observation, document reviews, and interviews, that Northern Light Eastern Maine Medical Center was in compliance, but previously out of compliance with 42 CFR, Part 489, Responsibilities of Medicare Participating Hospitals in Emergency Cases.”