Central Maine Medical Center Letters and Surveys

February 4, 2019
Dr. David Tupponce, M.D., President and CEO

Central Maine Medical Center
300 Main Street
Lewiston, ME 04240
Re: CMS Certification Number: 200024

Survey ID: IGT911, 01/11/2019
Initial Notice of Termination
Dear Dr. Tupponce:
Section 1865 of the Social Security Act (the Act) and Centers for Medicare & Medicaid
Services (CMS) regulations provide that a provider or supplier accredited by a
CMS-approved Medicare accreditation program will be “deemed” to meet all of the
Medicare Conditions of Participation (CoPs) for hospitals. In accordance with Section
1864 of the Act, State Survey Agencies may conduct at CMS’s direction, surveys of
deemed status providers on a selective sampling basis, in response to a substantial
allegation of noncompliance, or when CMS determines a full survey is required after a
substantial allegation survey identifies substantial noncompliance. CMS uses such
surveys as a means of validating the accrediting organization’s survey and accreditation
process.
A survey conducted by the Department Of Health And Human Services (State Survey
Agency) at Central Maine Medical Center on January 11, 2019 found that the facility was
not in substantial compliance with the following CoPs for hospitals:
42 CFR § 482.12 - Governing Body

42 CFR § 482.21 - QAPI
42 CFR § 482.55 - Emergency Services
As a result, effective January 11, 2019, your deemed status has been removed and survey
jurisdiction has been transferred to the State Survey Agency.
A listing of all deficiencies found is enclosed (Form CMS-2567, Statement of Deficiencies

and Plan of Correction).
When a hospital, regardless of whether it has deemed status, is found to be out of

compliance with the CoPs, a determination must be made that the facility no longer
meets the requirements for participation as a provider or supplier of services in the
Medicare program. Such a determination has been made in the case of Central Maine
Medical Center and accordingly, the Medicare agreement between Central Maine Medical
Center and CMS is being terminated. The date on which the Medicare agreement
terminates is May 4, 2019.
The Medicare program will not make payment for services furnished to patients who are
admitted on or after May 4, 2019. For inpatients admitted prior to May 4, 2019, payment
may continue to be made for a maximum of 30 days of inpatient services furnished on or
after May 4, 2019. You should submit as soon as possible, a list of names and Medicare
claim numbers of beneficiaries in your facility on May 2, 2019 to Nancy Hannah,
DHHS/CMS, JFK Federal Building, Room 2325, Boston, MA, 02203 to facilitate payment
for services to these individuals.
A public notice of termination will be posted on the CMS website at least fifteen days prior
to termination date at:
https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGe
nInfo/Termination-Notices.html
Termination can only be averted by correction of the deficiencies, through submission of an

acceptable plan of correction (PoC) and subsequent verification of compliance by the State
Survey Agency. The Form CMS-2567 with your PoC, dated and signed by your facility’s
authorized representative, must be submitted to the Maine State Survey Agency no later
than February 14, 2019. Please indicate your corrective actions on the right side of the
Form CMS-2567 in the column labeled “Provider Plan of Correction”, keying your
responses to the deficiencies on the left. Additionally, indicate your anticipated completion
dates in the column labeled “Completion Date”.
An acceptable PoC must contain the following elements:

1. The plan for correcting each specific deficiency cited;
2. The plan for improving the processes that led to the deficiency cited, including how the
hospital is addressing improvements in its systems in order to prevent the likelihood of
recurrence of the deficient practice;
3. The procedure for implementing the PoC, if found acceptable, for each deficiency
cited;
4. A completion date for correction of each deficiency cited;
5. The monitoring and tracking procedures that will be implemented to ensure that the
PoC is effective and that the specific deficiencies cited remain corrected and in
compliance with regulatory requirements; and
6. The title of the person(s) responsible for implementing the acceptable PoC.
Copies of the Form CMS-2567, including copies containing the facility’s PoC, are
releasable to the public in accordance with the provisions of Section 1864(a) of the Act and
42 C.F.R. § 401.133(a). As such, the PoC should not contain personal identifiers, such as
patient names, and you may wish to avoid the use of staff names. It must, however, be
specific as to what corrective action the hospital will take to achieve compliance, as
indicated above.
If an acceptable POC is timely submitted, your facility will be revisited to verify necessary
corrections. If CMS determines that the reasons for termination remain, you will be so
informed in writing, including the effective date of termination. If corrections have been
made and your facility is in substantial compliance, the termination procedures will be
halted, and you will be notified in writing.
If your Medicare agreement is terminated and you wish to be readmitted to the program,
you must demonstrate to the State Survey Agency and CMS that you are able to maintain
compliance. Readmission to the program will not be approved until CMS is reasonably
assured that you are able to sustain compliance.
If your Medicare agreement is terminated and you do not believe this termination decision
is correct, you may request a hearing before an Administrative Law Judge (ALJ) of the
Department of Health and Human Services, Departmental Appeals Board. Procedures
governing this process are set out in regulations at 42 C.F.R. Part 498. An appeal/request
for hearing must be filed no later than sixty (60) calendar days from the date of receipt of
the initial notice of termination.
You must file your appeal electronically at the Departmental Appeals Board Electronic
Filing System Web site (DAB E-File) at https://dab.efile.hhs.gov, unless you have received
approval from the Civil Remedies Division (CRD) to file in hardcopy. It is important that
you also send a copy of your request for hearing to this office to the attention of: Survey
Branch, Northeast Consortium Division of Survey & Certification, Centers for Medicare and
Medicaid Services (CMS), JFK Federal Building, Room 2275, Government Center, Boston,
MA 02203. A request for a hearing should identify the specific issues, the findings of fact
and the conclusions of law, if applicable, with which you disagree. You may be
represented by counsel at a hearing at your own expense.
If you have any questions, please contact Nancy Hannah at 617 565-1327.
Sincerely,
Lauren D. Reinertsen, M.P.A, Ph.D.

Associate Regional Administrator
Northeast Division, Survey & Certification
Enclosure: Form CMS-2567
cc: State Survey Agency

JC
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DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
300 MAIN STREET

CENTRAL MAINE MEDICAL CENTER
LEWISTON, ME 04240
(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE DATE
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A 000 INITIAL COMMENTS A 000
Federal Complaint # 29471
As complaint survey was conducted at Central

Maine Medical Center, an Acute Care Hospital, to
evaluate compliance with 42 Code of Federal
Regulations Part 482, Condition of Participation:
§482.12 Condition of Participation: Governing
Body, §482.21 Quality Assessment and
Performance Improvement, and §482.55
Condition of Participation: Emergency Services
was reviewed. This survey determined the
hospital was not in substantial compliance with
these conditions. The following requirements
have not been met:
A 043 GOVERNING BODY A 043
CFR(s): 482.12
There must be an effective governing body that is

legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions specified in this part that pertain to the
governing body ...
This CONDITION is not met as evidenced by:

Based on records reviewed and interviews, the
Condition of Participation (COP) for Governing
Body was not met as evidenced by the failure of
the Governing Body to ensure a thorough
analysis and quality assurance review was
conducted for an adverse event, and for the
failure to ensure the quality of care was
consistent with current standards of practice for 1
of 10 sampled patients.
Findings:
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IGT911 Facility ID: ME200024 If continuation sheet Page 1 of 14
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A 043 Continued From page 1 A 043
1. Condition: §482.21 Quality Assessment and

Performance Improvement Program also known
as A-0263 (QAPI). Based on records reviewed
and interviews, the hospital's system for quality
assurance failed to identify deficient practice and
opportunities for improvement related to
emergency services, adverse events, and
medical record accuracy for 1 of 10 sampled
cases. (Patient #1). Please see A0263 for
details.
2. Standard: §482.24(c)(4)(iv) - Documentation of

complications, hospital acquired infections, and
unfavorable reactions to drugs and anesthesia
also known as A0465. Based on interviews and
record reviews, the hospital failed to ensure the
medical record was complete and accurate
regarding documentation of complications for 1 of
10 sampled patients (Patient #1). Please see
A0465 for details.
3. COP: §482.55 COP: Emergency Services also

known as A-1100 Based on records reviewed and
interviews, the Condition Participation for
Emergency Services was not met as evidenced
by the failure to ensure care was provided in
accordance with current standards for 1 of 10
sampled patients presenting to the Emergency
Department (ED) (Patient #1). Please see A-1100
for details.
The cumulative effect of the deficient practices

resulted in noncompliance with this Condition of
Participation.
A 065 CARE OF PATIENTS - ADMISSION A 065
CFR(s): 482.12(c)(2)
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[ ...the governing body must ensure that the
following requirements are met:]
Patients are admitted to the hospital only on the
recommendation of a licensed practitioner
permitted by the State to admit patients to a
hospital.
This STANDARD is not met as evidenced by:
A 122 PATIENT RIGHTS: GRIEVANCE REVIEW TIME A 122

FRAMES
CFR(s): 482.13(a)(2)(ii)
At a minimum:
The grievance process must specify time frames
for review of the grievance and the provision of a
response.

Based on review of the hospital's grievance
process, the hospital failed to ensure that the
process clearly specified the time frame for
response to the Grievant.
Finding:
The hospital's "Patient Grievance Procedure

#HC-PA-2001", last revised 6/25/17, indicated
that "resolutions of most grievances should be
completed within seven business days of receipt
but not more than 30 days. Upon resolution of a
grievance, the Grievant will be provided with
written notification of the decision that includes
the contact person, steps that were taken on
behalf of the patient to investigate the grievance,
the results of the review and the date of the
completion."
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On 11/8/18, the hospital received a grievance
involving Patient #18.
On 12/19/18, the surveyor requested to review

the written notice provided to the patient. The
surveyor was informed that they had closed the
case on 12/6/18 and a written notice had not yet
been provided to the patient (41 days after receipt
of the grievance and 13 days after the case was
closed).
The hospital's policy and procedure in relation to

the time frame of the written notice was reviewed
with the Chief Quality Officer, the Registered
Nurse (RN) System Director for Risk, and the
Patient Advocate on 12/19/18 at 4:14 PM. The
surveyor was informed the the procedure was
"vague" in relation to when the notice was to be
provided to the Grievant.
A 123 PATIENT RIGHTS: NOTICE OF GRIEVANCE A 123
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.

Based on record reviews and interviews, the
hospital failed to provide a written notice that
contained the steps taken on behalf of the patient
to investigate the grievance and/or the results of
the grievance process for 2 of 4 patients who
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were involved in grievances filed (Patient #16 and
Patient #17). In addition, the hospital failed to
provide any notice to 1 of 5 patients who were
involved in grievances filed (Patient #18).
Findings:
The hospital's "Patient Grievance Procedure

#HC-PA-2001", last revised 6/25/17, indicated
that "resolutions of most grievances should be
completed within seven business days of receipt
but not more than 30 days. Upon resolution of a
grievance, the Grievant will be provided with
written notification of the decision that includes
the contact person, steps that were taken on
behalf of the patient to investigate the grievance,
the results of the review and the date of the
completion."
1. On 10/31/18, the hospital received a grievance

The written notice, dated 11/16/18, did not contain

the steps taken on behalf of the patient to
investigate the grievance and the results of the
grievance process.
This finding was discussed and confirmed in an

interview with the Chief Quality Officer, the
Registered Nurse (RN) System Director for Risk,
and the Patient Advocate on 12/19/18 at 3:45 PM.

The written notice, dated 11/29/18, did not contain

the results of the grievance process.
This finding was discussed and confirmed in an

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interview with the Chief Quality Officer, the
Registered Nurse (RN) System Director for Risk,
and the Patient Advocate on 12/19/18 at 3:59 PM.

On 12/19/18, the surveyor requested to review

the written notice provided to the patient. The
surveyor was informed that they had closed the
case on 12/6/18 and a written notice had not yet
been provided to the patient (41 days after receipt
of the grievance).
The hospital's policy and procedure in relation to

the timing of the written notice was reviewed with
the Chief Quality Officer, the Registered Nurse
(RN) System Director for Risk, and the Patient
Advocate on 12/19/18 at 4:14 PM. The surveyor
was informed the notice had not been provided to
the patient yet because of "busyness".
A 263 QAPI A 263
CFR(s): 482.21
The hospital must develop, implement and

maintain an effective, ongoing, hospital-wide,
data-driven quality assessment and performance
improvement program.
The hospital's governing body must ensure that

the program reflects the complexity of the
hospital's organization and services; involves all
hospital departments and services (including
those services furnished under contract or
arrangement); and focuses on indicators related
to improved health outcomes and the prevention
and reduction of medical errors.
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The hospital must maintain and demonstrate
evidence of its QAPI program for review by CMS.

Condition of Participation (CoP) for Quality
Assurance Performance Improvement (QAPI)
was not met as evidenced by the hospital's
Quality Assurance program's failure to identify
deficient practice and opportunity for
improvement related to emergency services,
adverse events, and medical record accuracy for
1 of 10 sampled cases.
Findings:
1. The hospital's Quality Assurance process failed

to ensure a thorough review and analysis of an
adverse event was completed timely and in
sampled cases reviewed. The hospital failed to
provide evidence to indicate that its QA process
identified medical record documentation
disparities regarding a nurse repositioning a
patient, or an immediate nurse assessment
related to that patient's response to the
repositioning, Please see A-0286 for details.
2. The hospital failed to ensure the disparities

between the documented physician assessment
of a patient's cervical and thoracic spine and
acceptable standards of practice for such
assessments were sufficiently reviewed in order
to identify process improvements to improve
health outcomes, please see A-1100 for details.

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Participation.
A 286 PATIENT SAFETY A 286
CFR(s): 482.21(a), (c)(2), (e)(3)
(a) Standard: Program Scope

(1) The program must include, but not be limited
to, an ongoing program that shows measurable
improvement in indicators for which there is
evidence that it will ... identify and reduce
medical errors.
(2) The hospital must measure, analyze, and
track ...adverse patient events ...
(c) Program Activities .....

(2) Performance improvement activities must
track medical errors and adverse patient events,
analyze their causes, and implement preventive
actions and mechanisms that include feedback
and learning throughout the hospital.
(e) Executive Responsibilities, The hospital's

governing body (or organized group or individual
who assumes full legal authority and responsibility
for operations of the hospital), medical staff, and
administrative officials are responsible and
accountable for ensuring the following: ...
(3) That clear expectations for safety are
established.
hospital's Quality Assurance process failed to
ensure a thorough review and analysis of an
adverse event was completed timely and in
sampled cases reviewed (Case #1).
Finding:
1. The hospital failed to provide evidence to
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indicate that its QA process identified medical
record documentation disparities regarding a
nurse repositioning a patient, or an immediate
nurse assessment related to that patient's
response to the repositioning.
2. The medical record for Patient #1 contained

documentation of physician assessment
techniques related to cervical spine assessment
and the conduction of full range of motion
assessment for a cervical spine injury which was
inconsistent with the standard of care for
treatment of known cervical spine injured
patients. The medical record also lacked
documentation of an incident nurse treatment
and repositioning of patient #1 which resulted in a
significant change to the patient. The hospital
failed to provide any evidence to indicate that the
QA Committee had identified the areas of an
inaccurate medical record and care inconsistent
with standards of practice as areas in need of QA
review and follow up.
A 465 CONTENT OF RECORD: COMPLICATIONS A 465
CFR(s): 482.24(c)(4)(iv)
[All records must document the following, as

appropriate:]
Documentation of complications, hospital

acquired infections, and unfavorable reactions to
drugs and anesthesia.

Based on interviews and record reviews, the
hospital failed to ensure the medical record was
complete and accurate regarding documentation
of complications for 1 of 10 sampled patients
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(Patient #1).
Finding
On 1/10/19 at 1:25 PM in an interview with RN #5

(day nurse) the nurse stated she "wasn't clear
regarding Patient #1's c-spine precaution orders,
questioned it, so she made Patient #1 strict
c-spine precautions until she could get
clarification ...had c-collar on ...Patient #1 did
speak of an increase in his/her numbness in BLE
[both lower extremities]" on her initial nurses
assessment.
On 1/7/19 at 08:28 AM while conducting an

interview with a family member, the surveyor was
informed that the family member was present
when the charge nurse entered Patient #1 room
and began to change the position of Patient #1
from flat to a head and upper body elevated
position. The family member stated that he/she
told the nurse he/she thought the ED physician
said Patient #1 was supposed to stay flat
because no x-rays of the back had been done
yet. The family member reports that the nurse
continued to elevate the head of the bed for
Patient #1 despite his/her screaming and the
family member reported the nurse's response
was, "the doctor ordered him to be sat up" ...
The medical record did not contain any
documentation of this incident or any evidence of
an assessment for a change of condition due to
the sudden increase in severe pain except for a
Neurosurgical note which stated " Thursday eve
pt admitted by trauma service ...placed/forced
into a 45-degree position by the staff, which
caused an acute loss of all motor function at that
time, in addition to causing a tremendous amount
of pain to the patient (this per patient and [family
member]). Apparently staff told the patient he
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'had to get to 45 degrees despite the pain' and he
lost all movement since that time."
A1100 EMERGENCY SERVICES A1100
CFR(s): 482.55
The hospital must meet the emergency needs of

patients in accordance with acceptable standards
of practice.

Condition Participation for Emergency Services
was not met as evidenced by the failure to ensure
care was provided in accordance with current
standards for 1 of 10 sampled patients presenting
to the Emergency Department (ED) (Patient #1).
Finding:
It is a standard practice for all patients who seek

care through the Emergency Department (ED) of
a hospital to receive a thorough
evaluation/assessment, stabilizing treatment, and
discharge to home or to previous living
environment in a stable condition, admission to
the hospital for continuing treatment, or transfer
to another hospital for further treatment that the
hospital is unable to provide. The complete
medical screening exam, including tests and
consults along with findings and the medical
decision related to stabilizing treatment,
admission, and/or discharge should be
documented in the record.
Documentation in Patient #1's medical record

indicated he/she presented to Hospital #1's ED by
Emergency Medical Services (EMS) on 10/4/18
at approximately 11:08 AM after sustaining a fall
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A1100 Continued From page 11 A1100

with loss of consciousness at a physician's office.
The medical record denoted that patient #1
arrived with spinal immobilization by EMS using a
rigid cervical collar and a long spinal
immobilization board. The medical record
contained documentation from a nurse (prior to
Patient #1's arrival) stating that Patient #1 had a
known fracture of the 4th Thoracic Vertebrae in
the spine and the right leg reported as worse than
normal.
On 10/4/18 at 12:17 PM the Emergency Room

physician documented in the medical record,
"Chief complaint of fall. History of present illness:
Patient comes to the ER with a complaint of
falling forward. Patient was at his/her spinal
surgeons office; he was bending forward, felt light
headed and fell onto his/her head. Patient claims
he/she has numbness to the right abodomen, and
down the right leg. Patient unsure if he/she lots
of consciousness, but does have neck pain and
back pain. He/she was recently diagnosed with a
herniated disks in the C-spine (cervical spine or
neck) and a compression fracture of T4 (thoracic
spine vertebrae #4) ... Physical Exam, Head:
Normocephalic, atraumatic; Neck: Supple,
trachea midline, no tenderness, no JVD (Juglar
Vein Distention) , no carotid bruit (Vascular
Murmur) ... Back: Nontender, normal range of
motion, Musculoskeletal: Normal strength, no
tenderness, no swelling, no deformity, decreased
range of motion of the right leg, decreased
sensation to the right leg ..."
On 10/4/18 at 12:40 PM a Cat Scan (CT) of the

Head and neck (Cervical spine) was conducted
and the ED physician contacted the on-call
Trauma physician after CT results which
indicated a skull fracture and a small fracture with
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fragments to one of the neck vertebrae (bones)
was obtained. In interview with the surveyor on
1/11/2019 the ED physician stated that "Patient
#1 was kept c-spine (neck) precautions with
cervical collar;" the ED physician stated that he
"contacted Trauma after CT results at 1:15 PM
and his (the ED physician) shift ended at 2:00
PM. Patient #1's care was considered in hands of
Trauma. The medical record contained
documentation from the ED physician which
stated, "Impression and plan diagnosis, Skull
fracture, facial laceration, C-spine facture."
On 10/4/18 at 3:30 PM the Surgeon covering

Trauma services, assessed Patient #1 and
documented in the medical record "[Patient #1 ]
complains of tingling and numbness from his/her
chest down to his/her feet but reports no
problems moving any of his/her extremities ...
Neck: 'Supple, full range of motion;
Musculoskeletal: no muscle pain , no bone pain,
no joint pain...Chronic back pain ... No gross
deformity of extremities. All extremities with full
range of motion; Neurologic: no headache, no
sensory changes." This documentation indicated
that the physician had the patient move his/her
head and neck in every possible way to
determine that the patient had "full range of
motion" and this is contrary to the standard of
care for a patient with a known cervical fracture.
There was no evidence in the medical record that

any diagnostic testing or evaluation of Patient
#1's existing T4 fracture to determine if any
exacerbation of that fracture existed from the fall
which resulted in loss of consciousness, a skull
and neck fracture was completed prior to or upon
admission. Additionally, the medical record
contained an admission order that stated, "HOB
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45 Degrees" (Head of Bed elevated to 45
degrees) with no mention of spinal precautions.
However, this would be inconsistent with the
standard of care given that there is no evidence
of an assessment of the existing T4 fracture after
the fall, and no mention of the stability of the
cervical fracture as seen on the CT scan
performed on 10/4/18. There was no admission
order in the medical record to denote that Patient
#1 was to be on spinal precautions. The failure to
conduct an assessment of a known spinal
fracture in the presence of a change in sensation
and a fall which resulted in another spinal fracture
is inconsistent with the standard of care.
On 1/10/19 at 1:25 PM in an interview with RN #5

(day nurse) the nurse stated she "wasn't clear
regarding Patient #1's c-spine precaution orders,
questioned it, so she made Patient #1 strict
c-spine precautions until she could get
clarification ...had c-collar on ...Patient #1 did
speak of an increase in his/her numbness in
BLE[both lower extremities]" on her initial nurses
assessment.

Participation.
April 22, 2019
Dr. David Tupponce, M.D, President

Central Maine Medical Center
300 Main Street
Lewiston, ME 04240
Re: CMS Certification Number: 200024

Extension of Termination Date Notice to June 30, 2019
Dear Dr. Tupponce:
The termination date of the Medicare Provider Agreement with Central Maine Medical
Center, originally scheduled for May 4, 2019, has been extended to June 30, 2019. This
determination has been made after review of the corrective actions your facility has
implemented, discussions with the Regional Office and State Agency and the review of
findings from on-site surveys, and consideration of the provider's current notice of additional
resources directed to corrective actions and its request for additional time to achieve
compliance with all Medicare Conditions of Participation.
The CMS determination to terminate the provider agreement was based on findings of a
substantial allegation survey dated January 11, 2019 that identified substantial
noncompliance (i.e., Condition-level deficiencies.) The existence of these significant
deficiencies transferred jurisdiction to the Maine State Survey Agency effective January 11,
2019, and Central Maine Medical Center was issued an initial notice of termination with a
termination date of May 4, 2019.
The Maine State Survey Agency conducted an additional substantial allegation survey dated
March 12, 2019 that identified additional substantial noncompliance with additional
Condition-level deficiencies.
The State Survey Agency conducted a revisit survey ending April 16, 2019 and determined
continued substantial noncompliance with the Conditions of Participation (CoPs).
Central Maine Medical Center must be in compliance with all Conditions of articipation
applicable to hospitals in order to participate in the Medicare program. In extending the
termination date, we emphasize that your facility 's compliance must be verified during an
unannounced Medicare revisit survey in order for termination proceedings to be rescinded.
If you have any questions concerning this matter, please contact Captain Hyosim
Seon-Spada at (617) 565 - 9160.
Sincerely,
Lauren D. Reinertsen, M.P.A, Ph.D.

Associate Regional Administrator
Northeast Division, Survey & Certification
cc: Maine State Survey Agency

JC
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A 000 INITIAL COMMENTS A 000
Federal Complaint: #29990, #29903 and #29996
Central Maine Medical Center, an Acute Care

Hospital, to evaluate compliance with 42 Code of
Federal Regulations Part 482, Condition of
Participation: Governing Body (§482.12),
Condition of Participation: Patient Rights:
(§482.13), Condition of Participation: Quality
Assessment and Performance Improvement
(§482.21), Condition of Participation: Emergency
Services (§482.55), and the Condition of
Participation: Discharge Planning (§482.58). This
survey determined the hospital was not in
substantial compliance with 42 Code of Federal
Regulations Part 482, Condition of Participation
for Governing Body (§482.12) and the Condition
of Participation for Emergency Services
(§482.55).
A 043 GOVERNING BODY A 043 4/4/19
CFR(s): 482.12
There must be an effective governing body that is

legally responsible for the conduct of the hospital.
If a hospital does not have an organized
governing body, the persons legally responsible
for the conduct of the hospital must carry out the
functions specified in this part that pertain to the
governing body ...

Condition of Participation (COP) for Governing
Body was not met as evidenced by the hospital's
failure to comply with the requirements of
§482.55 (Emergency Services) as evidenced in
the review of 1 of 9 sampled patients presenting
to the Emergency Department (ED) with chest
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
04/04/2019
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.
FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9ZSV11 Facility ID: ME200024 If continuation sheet Page 1 of 20
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pain (Patient #4).
Findings:
1. Standard: §482.12(f)(1) Emergency Services

also known as A-0092 - Based on record reviews
and interviews, the hospital failed to comply with
the requirements of §482.55 (Emergency
Services) as evidenced in the review of 1 of 9
Department (ED) with chest pain (Patient #4).
Please see A-0092 for details.
2. COP: §482.55 COP: Emergency Services also

known as A-1100 - Based on records reviewed
and interviews, the Condition of Participation for
Emergency Services was not met as evidenced
by the hospital's failure to provide care to a
patient presenting with chest pain in accordance
with current standards and policies for 1 of 9
Department (ED) with chest pain (Patient #4).
Please see A-1100 for details.

Participation.
A 092 EMERGENCY SERVICES A 092 4/4/19
CFR(s): 482.12(f)(1)
If emergency services are provided at the

hospital, the hospital must comply with the
requirements of §482.55.

hospital failed to comply with the requirements of
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to the Emergency Department (ED) with chest
pain (Patient #4).
Finding:
Based on record review and interviews, the

hospital failed to comply with the requirements of
to the ED with chest pain (Patient #4). See
A-1100 for details.
A 132 PATIENT RIGHTS: INFORMED DECISION A 132 4/8/19
CFR(s): 482.13(b)(3)
The patient has the right to formulate advance

directives and to have hospital staff and
practitioners who provide care in the hospital
comply with these directives, in accordance with
§489.100 of this part (Definition), §489.102 of this
part (Requirements for providers), and §489.104
of this part (Effective dates).

hospital failed to ensure it was documented if
patients had formulated an advance directive or if
they wanted to formulate an advance directive for
10 of 21 sampled patients (Patient #3, #4, #5, #6,
#7, #9, #10, #19, #20, and #21).
Findings:
The records for Patient #3, #4, #5, #6, #7, #9,
and #10, who had presented to the Emergency
Department, were reviewed. These patient
records showed no evidence to indicate the
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patient was asked if he/she had an advance
directive or if he/she would like to formulate an
advance directive.
The hospital's Advance Directive Policy, dated

5/25/17, indicated the following:
- B. Outpatient: "For Primary Care Practices, the

provider or their designee will make a best effort
to ask patients over the age of 65 if they have an
advanced directive. At the discretion of the
provider, younger patients or patients in specialty
practices diagnosed with a serious medical
condition may also be asked about advanced
directives."
- Under section Life Sustaining Treatment...

Documentation Whether Patients Have Executed
Advanced Directives A. As part of the admission
process for all adult inpatients, the staff person
involved will ask and document whether patient
has executed an advanced directive; e.g., living
will or durable health care power of attorney or
POLST...C. If the patient does not have an
advance directive and wishes additional
information or wishes to execute an advance
directive, the admission team member or the
nursing staff will offer the patient the Maine
Hospital Association's Health Care: Your Right to
Choose" packet."
This policy did not address the inquiry of advance

directives of patients who presented to the ED.
The hospital is required to provide written notice

of its policies regarding the implementation of
patients' rights to make decisions concerning
medical care, such as the right to formulate
advance directives.
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On 3/7/19 at 9:20 AM, the Clinical Quality

Registered Nurse confirmed there was no
documentation that patients presenting to the ED
had documentation in their records of being
asked about advanced directives or offered the
opportunity to formulate an advance directive.
She indicated the Registrar and the Clinical
Quality Department did not think the Emergency
Department is an applicable department as all
patients are full codes upon arrival and if the
patient asks for the advanced directive staff offer
the information according to policy.
On 3/7/19 at 2:09 PM, surveyors observed the ED

Registration process for Patient #18. This patient
was not asked about or offered advanced
directive information.
On 3/7/19 at 2:09 PM, an interview was

conducted with the Patient Access Specialist #1.
The Patient Access Specialist confirmed Patient
#18 was not offered an advanced directive during
registration because he/she was not 35 or over. It
is the Patient Access Specialist's preference as to
who is asked about or offered an advanced
directive.
On 3/7/19 at 2:24 PM, an interview conducted

with the Patient Access Specialist #2 confirmed
that sometimes when she does the registration in
the assigned patient emergency room, she asks if
the patient has a power of attorney or living will.
Usually, when she registers at the registration
window she asks or offers any patient 18 or over
if they have an advanced directive and if not; she
offers them the information.
On 3/7/19 at 12:05 PM, a surveyor interviewed

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Patient #20, who was in the ED. The patient was
asked if he/she received the "Health Care: Your
Right to Choose" booklet that contains
information of Advanced Directives (surveyor held
up the booklet) and the patient stated, "No, I
haven't seen one of those".
On 3/7/19 12:10 PM, a surveyor interviewed

up the booklet) and the patient stated, "I've got a
yellow folder before in the past, but not this time.
I've never seen that booklet your holding up
before, though."
On 3/7/19 at 12:22 PM, the surveyor interviewed

up the booklet) and the patient stated, "No, I
didn't receive that, yet". This patient stated he/she
entered the Emergency Department at
approximately 8:00 AM.
On 3/11/19 at 2:35 PM, in an interview with the

Director of Regulatory Compliance, the surveyor
informed her that Patients #19, #20 and #21 were
not provided with the "Health Care: Your Right to
Choose" booklet that contains information of
Advanced Directives, and the Director confirmed
the finding.
A 438 FORM AND RETENTION OF RECORDS A 438 4/2/19
CFR(s): 482.24(b)
The hospital must maintain a medical record for
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each inpatient and outpatient. Medical records
must be accurately written, promptly completed,
properly filed and retained, and accessible. The
hospital must use a system of author
identification and record maintenance that
ensures the integrity of the authentication and
protects the security of all record entries.

Based on record reviews and interview, the
hospital failed to ensure medical records were
accurate for 2 of 21 (Patient #4, and #5).
Findings:
1. The "Emergency Department Patient

Summary", dated 1/22/19, which was given to the
surveyor as part of this Patient #4's ED record,
indicated "The following procedures and tests
were performed during your ED visit". Laboratory
Tests - "CBC Diff"(a complete blood count with
differential); "Comprehen" (a comprehensive
metabolic panel); and "Troponin"; Radiology
Orders - "XR chest" (chest x-ray). There was no
evidence in the patient's record that these tests
were completed.
During an interview with Patient #4, via telephone

on 3/5/19 at 3:07 PM, he/she stated that no tests
other than an Electrocardiogram [EKG] were
performed during the Emergency Department
visit on 1/22/19.
On 3/7/19 at 3:20 PM, the Chief Quality Officer

and Systems Director of Quality were interviewed.
They stated that the Emergency Department
documents get created as the care evolves and
the information is prepopulated whether it
happens or not. They stated that they need to
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work with Cerner (the Medical Record System) to
correct this issue.
2. On 1/8/19 at 10:48 AM, the Emergency

Department (ED) Provider put in three separate
STAT (which means to be given immediately)
orders for Patient #5 to receive Lactated Ringers
(LR) 1,000 milliliters (ml) intravenously.
Documentation on Patient #5's Medical

Administration Record indicated that the patient
received 1000 mls (1 liter) of LR. However, the
ED Provider documented that the patient
received two liters of LR.
This patient record was inaccurate as in one

place it indicated one liter of LR was given and in
another place, it indicated two liters of LR was
given.
A1100 EMERGENCY SERVICES A1100 4/10/19
CFR(s): 482.55
The hospital must meet the emergency needs of

patients in accordance with acceptable standards
of practice.

Condition Participation for Emergency Services
was not met as evidenced by the hospital's failure
to provide care to a patient presenting with chest
pain in accordance with current standards and
policies for 1 of 9 sampled patients presenting to
the Emergency Department (ED) with chest pain
(Patient #4).
Finding:
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It is standard practice for patients who seek care
through the Emergency Department (ED) of a
hospital for chest pain and an elevated blood
pressure to receive a timely thorough
evaluation/assessment, stabilizing treatment, and
discharge to home or to previous living
environment in a stable condition, admission to
the hospital for continuing treatment, or transfer
to another hospital for further treatment that the
hospital is unable to provide.
On 1/22/19 at 5:13 PM, Patient #4, a 31 year old,

presented to the ED with a complaint of "chest
pain, dizzy".
On 1/22/19 at 5:20 PM, the Triage Registered

Nurse (RN) documented the following:
- The patient's chief complaint was "CP [chest

pain] and SOB [shortness of breath] since just
prior to arrival. No other assoc [associated] sx
[symptoms]".
- The patient's respiratory rate was 24 breaths per

minute and his/her blood pressure was 201/134.
- The patient's weight was 528 pounds.
- The patient's chest pain was documented to be

a "3" at rest on the numeric pain scale.
- The Emergency Severity Index (ESI) was "3-ED

Urgent".
- Allergies and previous active diagnoses.
At 5:16 PM, an electrocardiogram (EKG) was

ordered to be completed stat (immediately)
because the patient was experiencing chest pain.
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At 5:20 PM, the EKG was completed. The
reading, generated by the EKG machine,
indicated the patient was in "sinus rhythm" which
indicated this was a normal EKG. Documentation
completed at 5:21 PM, indicated a Physician was
notified of the EKG results.
At 7:09 PM or 7:10 PM, stat orders (orders to be

completed immediately) were entered into the
record by ED Physician #2 for the following: a
chest x-ray, the medications Nitroglycerin (a
medication for chest pain) and Metoprolol
(medication for blood pressure) and blood work,
including a troponin level (a lab test that is used
to determine heart muscle damage).
At 7:15 PM, ED Nurse #5 documented, "Per

registration, spoke with RN in pod to let them
know that pt. [patient] is leaving department".
At 7:27 PM, ED Nurse #5 documented the

following:
- Discharge Status: "stable"
- Disposition Date and Time: "1/22/19 1915" [7:15

PM]
- Disposition: "Left without being seen"
The "Emergency Department Patient Summary",

which was given to the surveyor as part of this
patient's ED record, indicated the following:
- ED Provider was ED Physician #5 who was

"assigned" on 1/22/19 at "7:10 PM" and was
unassigned on 1/22/19 at "7:13 PM".
- "The following procedures and tests were

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performed during your ED visit". Laboratory Tests
- "CBC Diff"(a complete blood count with
differential); "Comprehen" (a comprehensive
metabolic panel); and "Troponin"; Radiology
Orders - "XR chest" (chest x-ray).
The hospital's "Triage and Categorization of

Patients Policy", revised 12/17, was reviewed and
indicated the following:
- "Level 1: ED Resuscitation. Patient's presenting

with need for immediate emergency care for
loss/instability of vital life-sustaining functions or
an acute change in level of consciousness to the
point of being responsive only to painful stimuli or
completely unresponsive."
- "Level 2: ED Emergent. Patients presenting with

symptoms indicating a high-risk condition which
could easily deteriorate, symptoms suggestive of
a condition requiring time-sensitive treatment, an
acute change in mental status from patient's
baseline or severe pain/distress."
- "Level 3: ED Urgent. Patients presenting with

symptoms and stable vital signs that, if predicted,
the work-up and care would utilize 2 or more
resources to render an ED disposition."
- "Level 4: ED Semi-Urgent. Patients presenting

with symptoms that, if predicted, the work-up and
care would require only 1 resource to render an
ED disposition."
- "Level 5: Non-Urgent. Patients presenting with

symptoms that, if predicted, would require no
resource to render an ED disposition."
The hospital's "Chest Pain of Probable Cardiac

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Origin and Administration of Sublingual
Nitroglycerine" policy, revised 9/17, was reviewed
and indicated the following:
- "The Policy/Purpose Statement: To provide

patient safety and to provide for the initiation of
immediate care of the potential cardiac patient".
- "Upon determination through nursing

assessment that a patient is experiencing chest
pain and /or associated symptoms which may be
of cardiac origin, the emergency nurse will:
a. Notify the Charge Nurse of the patient's

condition and bring the patient to a room with
cardiac monitoring capabilities. Nursing will notify
the ED Provider (MD, PA [Physician Assistant],
NP [Nurse Practitioner]) of the patient's arrival.
b. Place the patient in a position of comfort.
c. Obtain STAT 12 lead EKG within 5 minutes of

arrival to the Emergency Department.
d. Attach the cardiac monitor to the patient.

Record, interpret and document lead II rhythm
strip. Consider instituting the cardiac 'Nursing
Standing Orders'.
e. Attach the pulse oximeter to the patient.

Document the oxygen saturation and administer
supplemental oxygen if:
i. Oxygen saturation is below 92%, or if
ii. Chest pain is present.
f. Reassure the patient and explain procedures

being performed.
g. Begin documenting pertinent history ...

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h. Take full set of vital signs, document in the

EMR and repeat as patient condition warrants.
i. Initiate venous access through an intermittent

intravenous cap. Draw blood for lab testing.
j. If chest pain is present and AFTER conferring

with the Emergency Department Provider,
administer sublingual nitroglycerine. (IV ACCESS
MUST BE ESTABLISHED PRIOR TO
ADMINISTRATION OF SUBLINGUAL
NITROGLYCERINE.)
k. Assist the Emergency Department Provider

with patient exam.
l. Listen to and document breath sounds.
m. Administer analgesia, anti-dysrhythmic and

other medications per provider order.
n. Obtain portable chest x-ray per Emergency

Department Provider order.
p. Ensure that lab orders have been entered.
q. Continually document patient's response to

interventions; notify the Emergency Department
Provider of any unanticipated responses or
deterioration in clinical condition.
r. Maintain communication with the patient's

family, keeping them informed of the patient's
condition. "
Based upon the hospital's "Triage and

Categorization of Patient's Policy", this patient
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should have been triaged at a level 2 based on
the patient's elevated blood pressure of 201/134;
not a level 3.
There was no evidence in Patient's #4's medical

record that indicated the following:
a. Between arrival at 5:15 PM and leaving at 7:15

PM, the patient was seen by a medical provider
or the medical provider was consulted despite the
patient's complaint of chest pain, elevated BP and
increased respirations.
b. The nursing staff assessed the patient between

5:20 PM and 7:15 PM when the patient left.
c. Attached the cardiac monitor to the patient per

the hospital's policy
d. Reassured the patient and explained

procedures being performed per the hospital's
policy
e. Initiated venous access through an intermittent

intravenous cap and drew blood for lab testing
per the hospital's policy.
f. Assessed breath sounds per the hospital's

policy.
g. Administered medications per the provider's

order.
h. Obtained the portable chest x-ray per the

Provider's order.
i. Ensured that lab orders had been entered into

the computer system.
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j. The stat orders for labs (a complete blood count
with differential; a comprehensive metabolic
panel; and troponin level), medications
(Nitroglycerin and Metoprolol), and chest x-ray
were completed.
On 3/05/2019 at 3:07 PM, Patient #4 was

interviewed via phone. The following information
was obtained during this interview:
- The patient confirmed he/she presented to the

ED around 5:15 PM on 1/22/19 after experiencing
left arm pain and chest pain about 30 minutes
before going to the ED.
- The patient described his/her symptoms as it if

"felt like my heart was stopping then it would start
up again double time ... it scared me".
- After an EKG was performed, he/she was sent

back to the waiting room where he/she waited
without being seen again for about an hour.
- After an hour, he/she and another patient in the

waiting room were called and brought into the
inner part of the ED at the same time. He/she and
his/her spouse was asked to wait in the hallway.
- While standing in the hallway, for about three

minutes, another staff member asked them if they
needed help. The patient explained that he/she
was told to wait in the hall by another staff
member. This staff member took the patient and
the patient's spouse to a room and stated that
she would inform the nurse that he/she was in the
room and someone would be in shortly.
- The patient stated that he/she and his/her

spouse were in the room for about 45 minutes
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and no one came back in.
- While in the room, the patient stated he/she

continued to have chest pain; he/she had not
been shown where the call bell was; and he/she
was not seen or examined by anyone.
- A little after 7:00 PM, the patient decided he/she

had waited long enough without being seen;
therefore, decided to leave. On the way out, the
patient and the spouse stopped at the registration
desk to let someone know they were leaving.
- Patient #4 stated the registration staff told

him/her it was a "big liability" for them if he/she
left without being seen. The patient explained the
situation (i.e.: he/she had sat in an exam room for
45 minutes and no one had come in to see
him/her).
- The patient expressed he/she felt where he/she

had chest pain that she should have been seen
and evaluated and he/she felt like they forgot
about him/her in the exam room.
- The patient confirmed he/she did not have any

labs drawn, a chest x-ray completed, or received
any medications during his/her ED visit.
- The patient confirmed that his/her blood

pressure had not been rechecked after the initial
reading.
- The patient confirmed that no staff other than

the triage nurse asked him/her again about
his/her chest pain.
On 3/07/2019 at 3:05 PM, the ED Triage Nurse,

who was on duty on 1/22/19, was interviewed.
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The following information was obtained during
this interview:
- If a patient presents with chest pain, an EKG

would be completed, vital signs would be
completed, and the nurse would obtain the
remaining required assessment information from
the patient or family member.
- The surveyor asked about the chest pain

protocol and he stated, "well, I'm sure an actual
protocol exists somewhere deep in the computer
system/files, but we go by what we think and
compare their symptoms to the Triage Level
guidelines we have ..." and he indicated these
guidelines are posted in the triage rooms.
- He confirmed the EKG was completed "per

chest pain protocol" and "if the Doctor was
concerned about the EKG results the ED tech
would have told me."
- He confirmed that the patient's "blood pressure

was high but [his/her] heart rate was normal
which made [him/her] a level 3 versus a level 2".
- The surveyor asked about the lab orders that

are part of the chest pain protocol. He stated, "I
could put the orders in under nursing protocols,
by clicking on the 'Chest Pain' box and a handful
of orders will populate, but that's only if I have the
time, the Doctor's out back can do it too."
- He indicate that they are told "'PULL TO FULL'

meaning if there is an empty bed we are going to
put a body in it, no matter if there is a Doctor or
Nurse available to see them ... they go on our
computerized screen, that we all can see, with a
blank space where the Provider and the Nurse
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are assigned, so that is how any of us know who
still needs to be seen that is in a room and who
already has an assigned caregiver. Whatever
nurse becomes available would pick them up ...
sometimes a provider sees the patient first ... they
are not automatically assigned a specific nurse
when they are brought back."
On 3/08/2019 at 10:00 AM, ED Nurse #6, was

interviewed via phone. The following information
was obtained during this interview:
- A patient will be placed on the computer board,

which means they are in a room in the inner part
of the ED waiting to be seen. The patient may or
may not be assigned a nurse or provider when
they are placed on the board.
- If a patient presents with chest pain, the

registration staff alerts the Triage nurse who
begins the triage process which would include an
EKG being completed. The EKG reading is taken
to the ED Provider by the staff who performed the
EKG and this staff person informs the Provider
with any additional information. The ED Provider
would inform the staff person if the patient
needed to come into the inner part of the ED who
then communicates this information to the Triage
Nurse.
- She confirmed that the Triage nurse can enter

orders such as labs and x-ray to expediate the
assessment process. If results were abnormal,
such as an elevated Troponin, then the patient
would be brought into the inner part of the ED
right away.
- The surveyor shared Patient #4's scenario and

she indicated that the patient should be triaged as
PRINTED: 05/01/2019
A. BUILDING ______________________
C
200024 B. WING _____________________________
03/12/2019
300 MAIN STREET

LEWISTON, ME 04240

TAG TAG
DEFICIENCY)

a Level 2; that orders would be completed, and
the patient would be brought into the inner part of
the ED right away.
On 3/08/2019 at 10:30 AM, ED RN #5 was

interviewed via phone. This surveyor asked her
about the "Emergency Department Patient
Summary" which she had printed on 1/22/19 at
7:27 PM. and the entry relation to the labs, x-ray,
and medication being given. She stated, "that is
an unfortunate thing about the patient summaries
because anything that is ordered, given, and or
done to a patient auto-populates to that summary
... even if it was not done or given".
On 3/08/2019 at 12:05 PM, ED Physician #2, who

was the physician who entered orders into the
patient's record, was interviewed via phone. She
indicated the following:
- She never saw Patient #4.
- She "saw [he/she] was in a room without a

nurse or provider signed up yet; I reviewed
[his/her] triage; saw [his/her] elevated blood
pressure and felt [he/she] needed Nitroglycerin to
help rid the chest pain and get the blood pressure
down; I ordered the Metoprolol PRN in case the
blood pressure didn't lower enough, labs and
x-rays to be done so the process could be started
for [him/her]. "I was told soon after I put all those
orders in that this patient had left without being
seen."
- "I remember feeling bad because I was not told

about this patient, I just happened to choose [him/
her] to help start things along if I could. If a nurse
would have come to me to let me know [he/she]
had these symptoms and wanted to leave I would
PRINTED: 05/01/2019
A. BUILDING ______________________
C
200024 B. WING _____________________________
03/12/2019
300 MAIN STREET

LEWISTON, ME 04240

TAG TAG
DEFICIENCY)

have at least gone to see [him/her] quickly, no
matter how busy, and talk to [him/her] and try to
convince [him/her] to stay so we could get these
tests done, make [him/her] feel better ... we
needed to get [his/her] blood pressure down and
get a Troponin level for sure."
This patient presented to the ED on 1/22/19 at

5:13 PM with chest pain and his/her blood
pressure was 201/134. The patient, after waiting
two hours and two minutes, left without being
seen (7:15 PM). The triage nurse identified the
patient as a level 3 despite his/her elevated blood
pressure; protocols, which two nurses indicated
could be initiated, were not; the hospital's "Chest
Pain of Probable Cardiac Origin and
Administration of Sublingual Nitroglycerine" policy
was not followed; the patient was not reassessed
after the initial triage assessment despite his/her
elevated blood pressure; and the patient was
never seen by an ED Provider in the two hour and
two minutes he/she was in the ED.

Participation.

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Central Maine Medical Center Letters and Surveys

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February 4, 2019

Dr. David Tupponce, M.D., President and CEO

Re: CMS Certification Number: 200024

Dear Dr. Tupponce:

42 CFR § 482.12 - Governing Body

A listing of all deficiencies found is enclosed (Form CMS-2567, Statement of Deficiencies

When a hospital, regardless of whether it has deemed status, is found to be out of

Termination can only be averted by correction of the deficiencies, through submission of an

An acceptable PoC must contain the following elements:

Lauren D. Reinertsen, M.P.A, Ph.D.

Enclosure: Form CMS-2567

cc: State Survey Agency

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 000 INITIAL COMMENTS A 000

Federal Complaint # 29471

As complaint survey was conducted at Central

There must be an effective governing body that is

This CONDITION is not met as evidenced by:

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 043 Continued From page 1 A 043

1. Condition: §482.21 Quality Assessment and

2. Standard: §482.24(c)(4)(iv) - Documentation of

3. COP: §482.55 COP: Emergency Services also

The cumulative effect of the deficient practices

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 065 Continued From page 2 A 065

This STANDARD is not met as evidenced by:

A 122 PATIENT RIGHTS: GRIEVANCE REVIEW TIME A 122

This STANDARD is not met as evidenced by:

The hospital's "Patient Grievance Procedure

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 122 Continued From page 3 A 122

On 12/19/18, the surveyor requested to review

The hospital's policy and procedure in relation to

This STANDARD is not met as evidenced by:

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 123 Continued From page 4 A 123

The hospital's "Patient Grievance Procedure

1. On 10/31/18, the hospital received a grievance

The written notice, dated 11/16/18, did not contain

This finding was discussed and confirmed in an

2. On 11/7/18, the hospital received a grievance

The written notice, dated 11/29/18, did not contain

This finding was discussed and confirmed in an

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 123 Continued From page 5 A 123

3. On 11/8/18, the hospital received a grievance

On 12/19/18, the surveyor requested to review

The hospital's policy and procedure in relation to

The hospital must develop, implement and

The hospital's governing body must ensure that

300 MAIN STREET

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)

A 263 Continued From page 6 A 263

This CONDITION is not met as evidenced by:

1. The hospital's Quality Assurance process failed

2. The hospital failed to ensure the disparities