Northern Light Blue Hill Hospital

BLUE HILL, Maine — Northern Light Blue Hill Hospital failed to safeguard some medical records and properly sanitize dishes, and its fire suppression system didn’t have access to enough water, a recent inspection revealed.

The federal Centers for Medicare and Medicaid Services survey of the 25-bed critical access hospital found it was “not in substantial compliance” with the requirements for receiving payments from Medicare when the series of inspections concluded July 17.

The surveys are typically performed by staff from the Maine Department of Health and Human Services by contractual agreement with the federal Medicare agency, said Jackie Farwell, DHHS spokeswoman.

“The hospital has submitted an acceptable plan of correction, which is evaluated consistent with CMS requirements,” Farwell said.

A representative of the hospital, which is listed as having finished correcting the problems on Nov. 8, said the organization responded adroitly to the survey.

“It is very common for state surveyors to identify opportunities for improvement,” said Kelley Anne Columber, a spokeswoman for Northern Light Health.

“Northern Light Blue Hill Hospital addressed all items identified and successfully satisfied the conditions of participation within the timeframe allotted. We are proud of the outstanding accolades we continue to receive from national organizations with regard to quality and safety,” she added in a statement.

Northern Light Blue Hill Hospital serves the Blue Hill peninsula. It is part of the $1.76 billion Northern Light health care system, which has grown in recent years to include nine hospitals stretching from Portland to Presque Isle. Northern Light is poised to grow larger through a pending merger with Mayo Regional Hospital in Dover-Foxcroft.

The violations were serious enough that the Centers for Medicare and Medicaid Services said they constituted an “immediate jeopardy” situation, in which some of the violations have caused or are likely to cause serious harm. Some violations had to do with the hospital having not implemented or reviewed written policies.

An inspection held July 16 revealed the water shortage in the hospital’s fire suppression system. According to the inspection report, the 9,000-gallon capacity tank was half full, and calculations showed that the system requires at least 25,920 gallons of water to meet National Fire Protection Association requirements.

“The hospital has an insufficient water supply to ensure the required minimum amount of water was available for the fire suppression system,” the report states. “If a fire were to break out, the local fire department is a volunteer fire department; therefore, would not be readily available to assist with fire control making it imperative that a sufficient amount of water was available.”

The problem is listed in the report as corrected as of Oct. 1, but the report does not say what was done. The Blue Hill Volunteer Fire Department is located at 65 Water St., yards away from the hospital at 57 Water St.

Unsanitary dish conditions were found when an inspector reviewed documents July 18 and saw that the hospital’s dishwasher used water below the recommended temperatures of 160 degrees Fahrenheit for the wash tank and 180 degrees for its final rinse cycle. The problem is listed as corrected on Aug. 8.

Patient records were improperly stored in two of three inpatient units — the Medical/Surgical Unit and the Special Care Unit — and the hospital’s Wound Clinic, one of seven outpatient areas, during an inspection on July 15, according to the report. In the Wound Clinic, for example, confidential patient records were kept in a closet that housekeeping staff could access.

“This finding was confirmed by a staff nurse at the time of the observation. The Nurse stated, ‘Housekeeping has access to the (closet) door key to clean when we aren’t here,’” according to the report.

A patient’s medical chart was left unattended on a nurse’s desk in the hospital’s Special Care Unit, during another inspection a day later, on July 16.