Report: CMMC failed to take precautions during COVID-19 outbreak

LEWISTON — Central Maine Medical Center allowed employees to walk through the hospital without masks, didn’t consistently or correctly screen workers and visitors entering the building, and failed to keep its Intensive Care Unit clean even as the hospital was dealing with a COVID-19 outbreak — an outbreak that started in the ICU — according to state investigators.

In a report issued in August and released this week to the Sun Journal, investigators said the hospital’s actions put people in immediate jeopardy, causing a situation in which a patient already had or likely could die or suffer serious injury. CMMC was ordered to quickly fix its problems, and hospital officials say they have.

CMMC’s COVID-19 outbreak began the third week of July and lasted well into August. In all, 17 people were infected, including 15 employees and two patients. According to the hospital, almost 50 people had to quarantine, most of them connected to the ICU.

The 32-page report details what CMMC did and didn’t do during that time:

• It did not implement all the infection control strategies it could have in order to prevent and control the transmission of COVID-19, nor was it monitoring the strategies it did have;

• It did not keep the ICU clean. Investigators noted dirt build up, overflowing trash, a dirty towel on the floor, splatter stains and brown stains on the floor, and IV tubing touching the floor, among other sanitation issues. Some dirty areas were in the hallway, others were in rooms.

Investigators said they were told housekeeping staff did not clean any room that had a COVID-19 patient in it. Investigators also said the system director of infection prevention told them that she had not seen the condition of ICU, the unit where CMMC’s outbreak began;

• It did not screen everyone who entered the building, despite U.S. Centers for Disease Control recommendations to do so. Temperature taking and screening questions were haphazard for both employees and visitors and nonexistent at some entrances, even as the hospital was in the middle of an outbreak;

• It did not monitor all entrances or ensure that only employees used employee entrances;

• It did not stay up to date on U.S. CDC guidelines. Hospital leaders told investigators they thought a fever was anything over 100.4 degrees, but the latest CDC guidelines set a COVID-concerning fever at 100 degrees;

• It did not screen employees once they got to their units, despite what appeared to be a new hospital policy requiring it.

“We used to get screened before coming into the hospital, but now we wear a mask and if we don’t have any of the symptoms, we are good to work. It is an honor system for screening in the morning. There is no screening to come onto this unit or for the lab,” a phlebotomist told investigators;

• It did not adequately document what was going on;

• It did not have enough signs with instructions about face coverings and hand washing;

• It did allow at least some employees to screen just once in June and then forgo future screening.

“After that date (June 25), we had the employees sign an attestation form one time, electronically, and then the only thing they do daily when they come in is get a new mask, if they don’t have one, and complete hand hygiene,” the hospital’s regulatory compliance coordinator told investigators;

• It did allow some employees to enter the hospital and walk through the building without a mask.

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When the investigation started, CMMC’s outbreak included 12 staff members and one patient. By the time the investigation was over, three more employees and one more patient had the virus.

John Alexander, chief medical officer for the health system, said CMMC immediately fixed the issues raised by investigators. The report acknowledged that CMMC officials quickly created a plan of correction and fixed the problems.

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Those fixes include better screening for employees and visitors, as well as entrances that are restricted and monitored.

“We’ve really enhanced our processes to the point where we feel we have one of the best screening standards in the state,” he said.

Alexander said some of the issues within the ICU, such as cleanliness, were the result of the outbreak, which caused dozens of ICU workers to quarantine and miss work. Without those staff members, he said, some paperwork fell behind.

“It wasn’t so much that we weren’t maintaining the environment, it was more that we weren’t maintaining the documentation to support how we were maintaining the environment,” he said. “And that’s an important part of what we do.”

Alexander also said checklists weren’t being maintained, which meant employees coming on shift didn’t know what had or hadn’t been done by the previous shift. When asked why staff members couldn’t see on their own that trash needed to be emptied or the floor was dirty, Alexander said, “I can’t answer that.”

Alexander said the state investigators, who work on behalf of the federal Centers for Medicare & Medicaid Services, or CMS, had been inspecting all Maine hospitals and arrived at CMMC as part of a routine screening. However, the report notes that investigators were there because a complaint had been filed against the hospital.

Alexander said he considers investigators to be good partners.

“We rely on them as another set of eyes to help us find areas where we may have opportunities for improvement,” he said. “We look forward to when those situations occur so that we can correct them and we can make sure we continue to work toward patient safety.”

CMMC has been the subject of a number of investigations in recent years, including last year when CMS investigators found a series of problems so serious that CMS threatened to stop paying for Medicare and Medicaid patients to go there. The hospital fixed those problems and did not lose payments.