Mainehealth Behavioral Health at Spring Harbor

“VENTILATION, LIGHT, TEMPERATURE CONTROLS CFR(s): 482.41(c)(4) There must be proper ventilation, light, and temperature controls in pharmaceutical, food preparation, and other appropriate areas. This Standard is not met as evidenced by: 46424 Based on interviews and record review the hospital failed to assure adequate water temperatures were maintained during the wash cycle for the kitchen dishwasher for one (1) of one (1) dishwasher. During record review of the daily kitchen temperature logs on 04/29/2026, at approximately 12:22 PM it was determined the facility failed to act on water temperature readings less than the identified minimum temperature for water used in the wash cycle. A document titled “Daily Temperature Log” including three (3) months data, (02/13/2026 - 04/28/2026), provided for multiple food service items in the hospital kitchen. The individual forms contained two (2) days data, broken down into three (3) readings at 6:00AM, 1:00 PM and 6:00PM. One section is titled “Dishwasher Wash Temp”, with an expected temperature of “Minimum 160 [degrees Fahrenheit]”. The temperature readings are reportedly taken from a display attached to the dishwasher and are not direct measurements by kitchen staff. The following readings were recorded for twelve (12) consecutive days: 04/28/2026 - 6:00AM - 141. 1:00 PM - 148. 6:00 PM - 170. 04/27/2026 - 6:00AM - 150. 1:00 PM - 149. 6:00 PM - 143. 04/26/2026 - 6:00AM - 155. 1:00 PM - 130. 6:00 PM - 170. 04/25/2026 - 6:00AM - 164. 1:00 PM - 148. 6:00 PM - 167. 04/24/2026 - 6:00AM - 154. 1:00 PM - 155. 6:00 PM - 165. 04/23/2026 - 6:00AM - 164. 1:00 PM - 145. 6:00 PM - 167. 04/22/2026 - 6:00AM - 155. 1:00 PM - 155. 6:00 PM - 166. 04/21/2026 - 6:00AM - 166. 1:00 PM - 147. 6:00 PM - 180. 04/20/2026 - 6:00AM - 154. 1:00 PM - 147. 6:00 PM - 161. 04/19/2026 - 6:00AM - 152. 1:00 PM - 162. 6:00 PM - 185. 04/18/2026 - 6:00AM - 156. 1:00 PM - 141. 6:00 PM - 184. 04/17/2026 - 6:00AM - 154. 1:00 PM - 147. 6:00 PM - 154. Twenty-two (22) of thirty-six (36) recorded temperature readings were below the required minimum temperature. The log from 02/12/2026 - 04/16/2026 contained an additional sixty-one (61) dates with at least one (1) reading below the required minimum temperature recorded each day. On 04/29/2026 during a meeting with the Director of Engineering and the Facilities Manager, it was reported that the hospital uses an electronic environmental tracking system that alerts engineering of any data outside of set norms. When the dishwasher temperature log was reviewed, it was reported the identified water temperature readings outside the expected minimums were not a known issue to the physical plant management team. It was reported that the kitchen environmental data is on “paper logs” and not immediately accessible. The information provided on the submitted “Daily Temperature Log” was confirmed by the Director of Engineering and the Facilities Manager at approximately 2:37 PM on 04/29/2026.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 49750 Based on document reviews, interviews and observations, the hospital failed to ensure nursing staff followed the hospital’s Standard Operating Procedure (SOP) Mouth Checks for eleven (11) of eleven (11) registered nurses observed via video tape reviewed. Findings: The hospital’s SOP titled, “”Mouth Checks, implemented on 01/21/2021” states in part, “ ...#7 Do full mouth check after administration, ask patient to expose inside of cheeks and lift tongue and observe under the roof the mouth ...”. Observations revealed the following: On 1/21/2026 at 2:03 PM, surveyors, via video footage, observed RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, RN #8, RN #9, RN #10, RN #11, and RN #12 dispense medication without performing a mouth check. On 1/21/2026 at 2:41 PM, PSCS #1 and PSCS #2 both agreed and confirmed that RN #2, RN #3, RN #4, RN #5, RN #6, RN #7, RN #8, RN #9, RN #10, RN #11, and RN #12 dispensed medication without performing a mouth check.”

“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: 50294 Based on document reviews and interviews, it was determined that the hospital failed to take appropriate actions to ensure the patient was free from physical abuse. 1. On Friday, September 12, 2025, at approximately 12:19pm, Patient #1 assaulted Patient #2 resulting in a broken nose and sore ribs. The following reasons shows deficient practice and keep the patient free from physical abuse. 2. Use of improper channels of communication (Epic Rover) by a Psychological Technician (Psy tech) #1, to report an urgent concern of Patient #1’s stated intent to physically harm Patient #2. Patient #1 approached the Psy Tech #1, and shared he had intrusive thoughts of, “wanting to punch Patient #2.” It is noted that the previous evening Patient #1 entered Patient #2’s room unauthorized and against protocol, placed a cup in a paper bag filled with his feces. 3. Psy tech #2 failed to receive a report concerning her 1:1 (one staff to one patient) assignment with Patient #2 and failed to receive the urgent concern from Psy tech #1, with the communication of the intent to physically harm Patient #2 thus not receiving that message. As per policy, she is not to carry the Epic Rover device while in a 1:1 assignment. This was confirmed by Nursing Director #1. A 1:1 assignment provides constant direct visualization from a trained staff member who will be stationed within arm’s length of their assignee. 4. Nursing Director #1 during interview stated in part ... “the [Epic] Rover (chat) is an informal communication tool. If there is a concern that a patient is being aggressive, you would not want to put that [communication] put in a chat. This should be communicated verbally. That is how Psy Tech #1 would have been trained.” She continued saying that the staff in general is aware but continues to use this mode of communication. 5. On September 24, 2025 at 11:10AM the Nursing Director #1 confirmed that the staff failed to follow hospital protocal by using the Rover for communication for a 1:1 assignment.”