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Based on record review, the facility failed to ensure that all medical record entries were timed when signed for 1 (#33) of 65 patient records reviewed. Findings include:

On 3/2/10 at 11:00 a.m., the medical record for patient #33 was reviewed. The following entries were not timed when signed by the physician:
- 2/22/10 - physician order;
- 2/24/10 - physician order;
- 2/26/10 - physician order;
- 3/1/10 - physician order;
- 2/22/10 - two progress notes;
- 2/23/10 - progress note:
- 2/24/10 - two progress notes;
- 2/25/10 - progress note;
- 2/26/10 - progress note;
- 2/28/10 - progress note;
- 3/2/10 - progress note.

Based on observation and staff interview, and record review, the facility failed to comply with the Condition of Participation for Physical Environment due to the nature and number of Life Safety Standard deficiencies as well as food service standards related to plumbing being deficient. Findings included:

1. Through record review and observation during the survey completed March 1-3, 2010, the following problems were identified:
a. Building construction: not maintaining 2-hour fire walls with non-conforming buildings and not maintaining floors, walls and ceiling ratings.

b. Interior finish: not maintaining corridors and exitways at least to Class A standards.

c. Exiting: not maintaining exit pathways clear and free of obstructions; not maintaining exit components (stairways) enclosed with construction having a fire resistance rating of at least 1 hour; not maintaining doors in smoke barrier compartments; and not maintaining width of aisles in exit corridors at least 8 feet.

d. Corridor walls & doors: not maintaining corridor barrier ratings at 20 minutes and not maintaining all corridor doors to be latching.

e. Vertical openings: not maintaining shafts, chutes, stairways and elevators fire resistance rating at least 1 hour; and not maintaining stairway enclosure doors or hazardous area enclosure doors.

f. Smoke barriers: not maintaining the 1/2 hour construction of smoke barriers.

g. Fire barriers: not maintaining the 2-hour construction of fire barriers.

h. Hazardous areas: not maintaining construction in hazardous areas, (walls, ceilings and doors).

i. Exits and Egress: not providing hard path surfaces to the public way for all exits.

j. Sprinkler Service: not all the information was being tracked which was required on the service reports.

k. Fire Watch Policy: Authority Having Jurisdiction (AHJ) was not being notified when the alarm or sprinkler system were down for more than 4 hours in a 24 hour period.

l. Sprinkler system: not all areas of the building were covered by the installed sprinkler system.

m. Portable extinguishers: not all portable fire extinguishers were being serviced every six years for the required maintenance and every twelve years for the hydrostatic testing.

n. Building service: sprinkler valves were not supervised.

o. Electrical: electrical devices and equipment did not meet the standards for the National Electric Code.

2. Based on the Administrative Rule of Montana for Food Service Establishments,¹ "Plumbing must be installed and maintained in a manner which prevents cross connections between the potable water supply and any non-potable or questionable water supply nor any source of pollution through which the potable water supply might become contaminated . . . There may not be a direct connection between the sewerage system and any drains originating from equipment in which food, portable equipment, or utensils are placed."
a. On 3/1/10 at 10:00 a.m., an initial tour of the kitchen was conducted. There was no air gap on the three compartment sink in the dish room. The dietary staff was in the process of washing pots and pans.

b. On 3/1/10 at 1:10 p.m., a maintenance staff member stated the 3 compartment sink was plumbed directly into the sewage system.


¹ Montana Department of Public Health and Human Services Food and Consumer Safety Section (2000). Food service establishments administrative rule 37.110.219. Helena, MT.

Based on the survey completed on March 1-3, 2010, and observation during the tour of the facility, it was determined the Standards of the 2000 National Fire Protection Association (NFPA) 101 Life Safety Code were not met. See the attached CMS form 2567 for specific Life Safety Code deficiencies and details.

Based on the findings of the Life Safety Code survey conducted at the hospital the week of March 1-3, 2010, this Standard is not met. Specific findings are listed in the separate Life Safety Code Statement of Deficiencies, CMS Form 2567.

Based on observation and staff interview the facility failed to provide procedures for the proper routine storage of garbage/trash. Findings include:

On 3/2/10 at 8:45 a.m., the environmental tour of the psychiatric unit was conducted. There was a soiled utility room that had one large red container partially full of paper bags containing trash, a second large yellow container that was partially full of trash, and a metal frame stand with a large plastic bag that was empty. There were several paper bags on the floor filled with trash. There was a very strong foul odor in the room.

On 3/2/10 at 9:00 a.m., an environmental services staff member was interviewed. He acknowledged the foul odor in the soiled utility room. He stated the three containers were to be used for the trash on the unit, however, staff put the paper bags with trash on the floor. He did not know of any specific policies or procedures for handling of garbage.

On 3/2/10 at 3:45 p.m., policies and procedures specific for handling of routine garbage/trash were requested.

On 3/3/10 at 8:00 a.m., administrative staff stated they did not have a specific policy for handling routine garbage /trash.

Montana Code Annotated section 37.106.320 MINIMUM STANDARDS FOR ALL HEALTH CARE FACILITIES:
PHYSICAL PLANT AND EQUIPMENT MAINTENANCE (1) Each facility shall
have a written maintenance program describing the procedures that must be utilized by
maintenance personnel to keep the building and equipment in repair and free from
hazards.
(2) A health care facility shall provide housekeeping services on a daily basis.

Based on observation and staff interview, the facility failed to ensure periodic maintenance of equipment in accordance with manufacturer's and Federal and State laws and regulations. Findings include:

During the tour of the physician clinic on 3/3/10 at 8:00 a.m., it was observed that none of the medical equipment had the biomedical sticker indicating it had been serviced or inspected by the biomedical department.

The nurse manager informed the surveyor on 3/3/10 at 9:10 a.m., that she had discussed with the biomedical department and the medical equipment had not been maintained at the clinic as required and per the hospital policy.

Based on staff interview, the facility failed to prepare radio pharmaceuticals under the direct supervision of an appropriately trained pharmacist or physician. Findings include:

During the tour of the nuclear medicine department, on 3/2/10 at 7:30 a.m., the nuclear medicine technician stated that only about 10 percent of the radio pharmaceuticals were prepared in-house by the nuclear medicine technician. The surveyor asked if the technician was directly supervised by a physician or pharmacist when the radio pharmaceutical was prepared. The technician stated, "the radiologist is on-call so I guess that would be indirectly".