HospitalInspections.org

Based on observation, record review, and staff interview, it was determined that the CAH failed to maintain the physical plant in a manner that provided a safe, clean, and functional environment for the patients, public, and staff. The Condition of Participation of Physical Plant and Environment was not met as evidenced by the following findings:

1. Failure to have in place preventive maintenance programs to ensure that all essential mechanical, electrical, and patient care equipment is maintained in a safe operating condition. Refer to C 222.

2. Failure to ensure that the facility had an up-to-date Fire Watch Policy. Refer to C 227.

3. Failure to ensure that maintenance staff performed quarterly fire drills per shift. Refer to C 230.

4. Failure to meet the 2000 NFPA 101 Life Safety Code. Refer to C 231.

5. Failure to ensure that maintenance staff performed monthly and annual preventive maintenance on all emergency lighting battery packs. Refer to C 235.

6. Failure to install Alcohol Based Hand Rub dispensers correctly in all patient care areas. Refer to C 237.

Based on observations and staff interview, the facility failed to ensure that patient care supplies were maintained to ensure an acceptable level of safety and quality for all patients seen in the hospital. Findings include:

1. During the review of the Medical/Surgical floor medication room on 10/25/10 at approximately 3:00 p.m., the surveyor observed the following expired patient care items:
- 17 24 ga. by 3/4 in. Insyte intravenous catheters with the manufacturer's expiration dates of 6/2009 (1), 11/2009 (1), 9/2010 (3), and 7/2010 (12).

On 10/25/10 at approximately 3:00 p.m., staff member G stated that staff check dates of expiration for supplies every month.

2. During the review of the Emergency Department on 10/26/10, beginning at 8:00 a.m., the surveyor observed the following expired patient care supplies:
- 1 gallon Betadine surgical scrub with the manufacturer's expiration date of 7/2010.
- 4 16 ga. by 1 1/4 in. Jelco intravenous catheters with the manufacturer's expiration date of 6/2010.
- 1 bottle of 1/2 in. by 5 yards Kendall sterile plain packing strip with the manufacturer's expiration date of 7/2010.
- 1 Portex 23 ga. by 1 in. sterile needle with cover with the manufacturer's expiration date of 8/2008.

Staff member I verified the expiration dates of the supplies.

3. During the survey of the operating room on 10/26/10 at 12:45 p.m., the surveyor observed the following expired patient care supplies:
- 1 sterile Megadyne Electronic pencil with the manufacturer's expiration date of 11/2009.
- 4 sterile Povidone Iodine individual swabsticks with the manufacturer's expiration date of 6/2010.
- 16 sterile Tincture of Benzoin swabsticks with the manufacturer's expiration date of 7/2010.
- 30+ Portex 25 ga. by 5/8 in. sterile needles with covers with the manufacturer's expiration date of 8/2010.

Staff member C verified the expiration dates of the identified supplies and stated that staff members check supply dates monthly.

4. During the survey of the radiology department on 10/27/10 at approximately 9:00 a.m., the surveyor observed the following expired patient care supplies:
- 6 22 ga. by 1 in. Insyte Autoguard intravenous catheters with the manufacturer's expiration date of 2/2010.



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5. Based on observation, the facility failed to maintain the electrical wiring and equipment in accordance with National Fire Protection Association (NFPA) 70. Refer to K 147 of the Fire Life Safety survey.

Based on record review and staff interview, the facility failed to ensure that emergency procedures, and training of staff in handling emergencies were maintained to ensure an acceptable level of safety and quality for all patients, staff and guests. Findings include:

- The facility lacked an updated copy of a Fire Watch Policy. Refer to K 154 and K 155 of the Fire Life Safety survey.

Based on review of the fire drills received by FAX on 11/1/2010, the facility failed to develop appropriate responses that would ensure the safety and well being of the patients, visitors/guests, and staff.

Findings include:

The facility failed to document fire drills appropriately. Refer to K 50 of the Fire Life Safety survey.

Based on observation, record review and staff interview, the facility failed to meet the applicable provisions of the 2000 edition of the Life Safety Code.

Findings include:

- Proper separation of fire walls at two hour walls. Refer to K 11.
- Building construction. Refer to K 12.
- Corridor walls and doors. Refer to K 17.
- Obstructions to corridor doors. Refer to K 18.
- Doors in exit passageways, stairway enclosures, horizontal exits, or smoke barriers. Refer to K 21.
- Exit signs. Refer to K 22.
- Hazardous areas. Refer to K 29.
- Separation between levels at stairways. Refer to K 33
- Hard path surfaces at all exits to a public way. Refer to K 38.
- Maintenance requirements for emergency lighting battery packs. Refer to K 46.
- Maintenance of exit signs. Refer to K 47.
- Maintenance record of all required fire drills. Refer to K 50.
- Identification of Fire Alarm Control Panel and connection means. Refer to K 52.
- Complete sprinkler coverage for all areas of the Critical Access Hospital. Refer to K 56.
- Maintenance of sprinkler system. Refer to K 62.
- Wall hangings be treated with flame spread material. Refer to K 73.
- Draperies, curtains and valances be treated with a flame spread material. Refer to K 74.
- Oxygen tanks be secured. Refer to K 76.
- Medical gas and oxygen storerooms be labeled. Refer to K 78.
- No smoking signs be posted where oxygen is stored. Refer to K 141.
- Electrical wiring in accordance with NFPA 70. Refer to K 147.
- Up-to-date Fire Watch Policy. Refer to K 154 and K 155.
- All Alcohol Based Hand Rub dispensers located properly. Refer to K 211.

Based on observation and record review for facility emergency lighting, the facility failed to document that the emergency lighting was maintained properly. Findings include: Refer to K 46 in the Fire Life Safety survey.

Based on observation, the facility failed to locate Alcohol Based Hand Rub dispensers properly. Findings include: Refer to K 211 of the Fire Life Safety survey.

Based on document reviews and staff interview, the facility governing body and responsible individual failed to ensure that all policies for operation of the CAH were followed. Findings include:

1. During the review of provider credential files on 10/27/10, the surveyor noted that the facility governing body had not reviewed the credentialing information, made a recommendation for active status, acted on the recommendation and granted active status to staff member U. Staff member U was appointed to the position of chief of staff of the hospital while granted membership in the medical staff at the provisional staff level. The physician had been on provisional status for a period of two years.

The Medical Staff Bylaws, section 3.5, Provisional Status, reads under item 3.5-4 Term of Provisional Status, "A member shall remain in the provisional staff for a period of six months, unless the status is extended by the Medical Executive Committee for an additional period of up to one year upon determination of good cause, which determination shall not be subject to review pursuant to Articles 9 or 10."

The facility Medical Staff Bylaws state under Article 6. Officers, section 6.1-2, Qualifications, that officers must be active members of the medical staff.



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2. The Medical Staff By-laws, revised October 2010, section 4.5 and 4.6 address the requirements of an initial appointment and reappointment. In addition, the Reappointment Policy for Medical Staff.0003 stated that reappraisals of the medical staff would be completed every 2 years.

The following staff members credentialing files were reviewed:
3. Staff member U's file included a letter dated 6/2/08, stating he was granted temporary privileges to perform surgery procedures in accordance with his training and experience. These temporary privileges would remain in effect up to 90 days or until Medical Staff (meeting June 9th) and the Board of Trustees (meeting June 3rd) agree to grant provisional privileges. This was signed by the Chief of Staff. Hand written on this letter was "provisional granted June 3rd 2008". There was no indication the Board of Directors approved this appointment. This file lacked documentation of reappointment or a periodic appraisal. On 10/27/10 at 3:45 p.m., staff member K, Human Resources Director/Medical Staff Secretary, stated staff member U should have been "active" but this was never completed. Staff member U was currently the Chief of Staff.

4. Staff member W's, Certified Registered Nurse Anesthetist, credentialing file contained a document titled "A Performance Improvement Network Summary of Credentialing Process Reappointment". This form included a section that read, "Based on review of the above information, the Medical Staff and Northern Rockies Medical Center Board of Trustees _ recommends appointment _ does not recommend appointment." There was no indication that the Medical Staff and the Board of Trustees approved or disapproved the reappointment. This form had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated. A Reappointment Recommendation for a reappointment time period from 2007-2009 had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated.

5. Staff member X, radiologist, was approved for Courtesy Staff in February 2003. A Performance Improvement Network Summary of Credentialing Process Reappointment was included in the file. This form included a section that read, "Based on review of the above information, the Medical Staff and NRMC Board of Trustees _ recommends appointment _ does not recommend appointment." There was no indication that the Medical Staff and the Board of Trustees approved or disapproved the reappointment. This form had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated. A Reappointment Recommendation for a reappointment time period from 2007-2009 had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated. A form letter, not addressed to a specific physician, dated 2/15/10, read, "As of this date, the NRMC Board of Trustees and Medical Staff have approved your application for continuing your Courtesy Privileges...." This letter was signed by staff member U.

6. Staff member Y, radiologist, was approved for Courtesy Staff in February 2003. A Performance Improvement Network Summary of Credentialing Process Reappointment was included in the file. This form included a section that read, "Based on review of the above information, the Medical Staff and NRMC Board of Trustees _ recommends appointment _ does not recommend appointment." There was no indication that the Medical Staff and the Board of Trustees approved or disapproved the reappointment. This form had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated. A Reappointment Recommendation for a reappointment time period from 2007-2009 included an appraisal section indicating satisfactory, needs improvement and unsatisfactory. This section of the Reappointment Recommendation lacked documentation. The Reappointment Recommendation had signature sections for the Chief of Staff, which was signed by staff member U on 11/13/09, and the Board of Trustees Chair, which was not signed or dated.

Based on document review and staff interview, the facility failed to provide the State Agency with the name and address of the person principally responsible for the operation of the CAH. Findings include:

During the pre-survey review of the information on 10/18/10, regarding the administrative staff of the CAH, the surveyor noted the name of the chief executive officer (CEO) for the facility. Upon entry into the facility on 10/25/10 at 10:30 a.m., the survey team was introduced to staff member F as the acting CEO for the facility. This was not the person identified during the off-site review.

Review of the facility governing body meeting minutes on 10/27/10 at approximately 2:00 p.m., revealed that the documented CEO had tendered his resignation in June of 2010, and had left the position in September 2010. Staff member F took over as the acting CEO in early October 2010. His tenure as the acting CEO was ending on 10/29/10 and the new CEO was to start on 11/1/10.

In a phone conversation with state agency staff on 10/26/10 at 9:47 a.m., the office secretary stated that she had checked the facility file and checked with the staff of the Licensure Bureau and there was no record of notification of change of leadership in the file since the previous CEO came to the facility.

During the end of the day meeting with the facility administrative team at 4:30 p.m. on 10/26/10, the issue of the failure to notify the State Agency of the change of the responsible individual was identified. Staff member F, the acting CEO, stated that he was unaware that the state agency needed to be notified of the change of CEO.

Based on document review and staff interview, the facility failed to maintain a current list of the services the CAH furnishes directly and those furnished through agreement or arrangement. Findings include:

During the entrance conference with staff member F, acting chief executive officer (CEO), on 10/25/10 at 10:30 a.m., the survey team requested a current list of services furnished directly or through agreement or arrangement at the CAH.

The information was requested during the end of the day meeting with the facility management team at 4:30 p.m. on 10/27/10, and again on 10/28/10 from staff members F and M, the risk manager.

Staff member F stated that staff member M, had the list. In an interview with staff member M on 10/28/10 at approximately 10:00 a.m., staff member M stated that she was not aware of the existence of the list of services.

Based on document review and staff interview, the facility failed to maintain a current list of guidelines for the medical management of health problems that included the conditions requiring medical consultation and/or patient referral and procedures for the periodic review and evaluation of the services furnished by the CAH. Findings include:

During the entrance conference with staff member F, the acting chief executive officer (CEO), on 10/25/10 at 10:30 a.m., the survey team requested a current list of guidelines for the medical management of health problems that include the conditions requiring medical consultation and/or patient referral and procedures for the periodic review and evaluation of the services furnished by the CAH.

The information was requested during the end of the day meeting with the facility management team at 4:30 p.m. on 10/27/10, and again on 10/28/10 from staff members F and M, the risk manager.

Staff member F stated that staff member M had the list. In an interview with staff member M on 10/28/10 at approximately 10:00 a.m., staff member M stated that she was not aware of the existence of the list of guidelines.

Based on staff interview and record review, the CAH failed to ensure nutritional needs of inpatients were met in accordance with recognized dietary practices and failed to ensure a qualified dietitian supervised the nutritional aspects of patient care. The findings include:

On 10/25/10 at 2:05 p.m., staff member M, swing bed manager, stated the dietitian resigned 3-4 months ago. There was no current signed contract with a dietitian. She stated the facility had a contract with Glacier Care Center to provide meals.

Review of resident #s 34, 35, 36, and 37 medical records, lacked an assessment by a registered dietitian.

1. On 10/25/10 at 4:00 p.m., the dietary manager at Glacier Care Center stated the facility provided three types of diets which included a controlled carbohydrate 1800 calorie ADA (American Dietetic Association), a renal diet, and a cardiac diet. If a physician wrote an order for a 2 gram sodium diet, or a low fat, low cholesterol diet, the strictest of the three above listed diets was provided.

2. Resident #35 was admitted to the facility on 7/10/10 with diagnoses including, paraplegia, stage IV decubitus ulcer, diabetes, chronic obstructive pulmonary disease, osteomyelitis, and rheumatoid arthritis. The medical record lacked a nutritional assessment. The physician ordered a 1500 calorie ADA diet. A 1500 calorie ADA diet was not a diet that was offered by Glacier Care Center. According to the Nutrition Care of the Older Adult, Second Edition dated 2004, page 194 stated, "A nutrition assessment of the older adult should include a physical assessment of the condition of the skin. The older adult is at risk for the development of pressure ulcers based on multiple risk factors, including physical limitations, disease conditions, and medical treatments.... The dietetics professional should be an active participant on the wound care team that monitors healing and recommends protocol changes to advance the healing process. Frequent and detailed documentation in the medical record should support nutrition interventions recommended."

3. Resident #36 was admitted to the facility on 10/7/10 with diagnoses including congestive heart failure, macular degeneration, and valvular heart disease. The medical record lacked a nutritional assessment. The physician ordered a 2 gram sodium 1500 fluid restriction diet. A 2 gram sodium 1500 fluid restriction diet was not a diet that was offered by Glacier Care Center. A 10/13/10 Nurse's Notes, at 6:45 a.m., stated, "Refused Lasix initially but was eating ham for bkft [breakfast] therefore talked pt [patient] into taking it." According to the Manual of Clinical Dietetics Sixth Edition dated 2000, Guidelines for Food Selection for a 2 gram sodium diet, excluded or limited items included any smoked, cured, salted, koshered, or canned meat, fish, or poultry including bacon, chipped beef, cold cuts, ham..."

4. Resident #37 was admitted to the facility on 10/1/10 with diagnosis including anxiety, chronic obstructive pulmonary disease, and stage IV decubitus ulcer. The medical record lacked a nutritional assessment and a diet order by the physician. According to the Nutrition Care of the Older Adult, Second Edition dated 2004, page 194 read, "A nutrition assessment of the older adult should include a physical assessment of the condition of the skin. The older adult is at risk for the development of pressure ulcers based on multiple risk factors, including physical limitations, disease conditions, and medical treatments.... The dietetics professional should be an active participant on the wound care team that monitors healing and recommends protocol changes to advance the healing process. Frequent and detailed documentation in the medical record should support nutrition interventions recommended."

Based on document review and staff interview, the facility failed to ensure that the CAH had agreements or arrangements (as appropriate) with one or more providers or suppliers participating under Medicare to furnish other services to its patients. Findings include:

1. During the entrance conference with staff member F, the acting chief executive officer (CEO), on 10/25/10 beginning at 10:30 a.m., the survey team provided staff member F with a list of requested information that included a request for a copy of the current list of agreements and contracts for services with one or more providers or suppliers participating under Medicare to furnish other services to its patients. Staff member F provided the survey team with a list that consisted of four contracted services, pathology, radiology interpretation, meal service, and telepharmacy services, and the actual contracts with those service providers. The list provided to the survey team did not include transfer agreements with other facilities for care of patients that required services beyond the capability of the facility.

The request for the complete list was repeated at 4:30 p.m. on 10/27/10, during the end of day meeting with the facility management team, and to the staff member F again in the morning of 10/28/10. Staff member F provided the survey team with a partial list of contracts and services during the exit conference on 10/28/10 at 1:00 p.m.

Review of the supplied contracts revealed that three of the four contracts were currently in effect. The fourth contract had expired. There was no documentation available that the contracts had been reviewed and evaluated since 2007 by the CEO, or the governing body.


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2. The Dietary Contract signed on 6/27/06, stated that Glacier Care Center (GCC) would provide three main meals approved by the dietitian to the patients of the Northern Rockies Medical Center. There was no indication this contract had been reviewed. The dietary manager at GCC stated they were not providing meals to children less than one year old. This information was not included in the contract language. She also stated that if there was a concern with a diet order, she was unable to confer with a hospital dietitian.

Based on document review and staff interview, the facility failed to maintain a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. Findings include:

During the entrance conference with staff member F, the acting chief executive officer on 10/25/10 beginning at 10:30 a.m., the survey team provided staff member F with a list of requested information. This list included a request for a copy of the current list of all services and contracts for services that included the scope and nature of those agreements and contracts. Staff member F provided the survey team with a list that consisted of 4 contracted services, pathology, radiology interpretation, meal service, and telepharmacy services.

The request for the complete list was repeated at 4:30 p.m. on 10/27/10, during the end of day meeting with the facility management team, and to the staff member F again in the morning of 10/28/10. Staff member F provided the survey team with a partial list of contracts and services during the exit conference on 10/28/10 at 1:00 p.m.

In an interview with staff member F on 10/26/10 at 4:30 p.m., staff member F stated that there was no current list of contracts and agreements for the facility and that staff member F was reviewing all facility contracts and agreements and was creating the list as the survey continued.

Based on document review and staff interviews, the facility chief executive officer (CEO) failed to maintain a list of all services furnished under arrangements or agreements. The list describes the nature and scope of the services provided. Findings include:

During the entrance conference with staff member F, the acting CEO, on 10/25/10 beginning at 10:30 a.m., the survey team provided staff member F with a list of requested information that included a request for a copy of the current list of all services and contracts for services including the scope and nature of those agreements and contracts. Staff member F provided the survey team with a list that consisted of 4 contracted services, pathology, radiology interpretation, meal service, and telepharmacy services, and the actual contracts with those service providers.

Review of those supplied contracts revealed that three of the four contracts were currently in force. The fourth contract had expired. There was no documentation available that the contracts had been reviewed and evaluated since 2007.

In an interview with staff members E, the chief financial officer, and K, the medical staff secretary, on 10/26/10 at 11:20 a.m., both staff members stated that there was no current list of contracts and agreements. Staff member K stated that there had been efforts to compile the list with the previous CEO, "but the effort had been placed on the back burner".

The request for the complete list was repeated at 4:30 p.m. on 10/27/10 during the end of day meeting with the facility management team, and to staff member F again on the morning of 10/28/10. Staff member F provided the survey team with a partial list of contracts and services during the exit conference on 10/28/10 at 1:00 p.m.

In an interview with staff member F on 10/26/10 at 4:30 p.m., staff member F stated that there was no current list of contracts and agreements for the facility and that staff member F was reviewing all contracts and agreements and he could find no evidence that the contracts had been reviewed.

Based on document review and staff interview, the facility chief executive officer (CEO) failed to maintain a list of all services furnished under arrangements or agreements and that those services complied with all applicable conditions of participation. Findings include:

During the entrance conference with staff member F, the acting CEO, on 10/25/10 beginning at 10:30 a.m., the survey team provided staff member F with a list of requested information that included a request for a copy of the current list of all services and contracts for services including the scope and nature of those agreements and contracts. Staff member F provided the survey team with a list that consisted of 4 contracted services, pathology, radiology interpretation, meal service, and telepharmacy services, and the actual contracts with those service providers.

Review of the supplied contracts revealed that three of the four contracts were currently in force. The fourth contract had expired. There was no documentation available that the contracts had been reviewed and evaluated for compliance with the conditions of participation since 2007.

In an interview with staff member F on 10/26/10 at 4:30 p.m., staff member F stated that there was no current list of contracts and agreements for the facility. Staff member F stated he was reviewing all contracts and agreements and he could find no evidence that the contracts had been reviewed since 2007.

Based on observations, document review, and staff interviews, the facility failed to provide on-going supervision and direction to ensure that nursing services at the facility met the needs of the patients served at the facility. Findings include:

During the entrance conference with staff member F, the acting facility CEO (chief executive officer), on 10/25/10 beginning at 10:30 a.m., staff member F stated that the facility did not currently have a director of nursing, or a nurse designated to cover the position.

The survey team noted that on every hallway, a list of open positions at the facility were posted.
The position of director of nursing was on those lists.

In an interview with staff member G, a staff nurse, on 10/25/10 at approximately 12:30 p.m., staff member G stated that she did not have a supervisor, as the facility had not had a director of nursing for months. Staff member G stated that the director of nursing had resigned in September of 2009. The facility had hired another director of nursing that was employed for approximately 6 months before she quit some 3 months ago.

Based on record review and staff interview, the facility failed to ensure medical records were accurately documented and complete for 3 (#s 34, 35, and 37) of 37 patient records sampled. Finding include:

1. Patient #34's record contained the following documents which were not complete:
-a Resident Restraint C [consent] which did not include completion of the following documented areas; the reason for the use of the restraint, the time of the resident's signature, the time of the witness signature, and if a physician order had been obtained including medical symptoms/condition.
-an Admit and Standing Orders for Admission to Swing Bed lacked the time of entry; and
-a Swing Bed Nursing Admission Assessment lacked the date and time after the signature of the admitting nurse.

2. For patient #37, the Swing Bed Resident Rights and Responsibilities form was not signed or dated by the resident or authorized representative or staff. A Minimum Data Set for Swing Bed Hospital form was not signed or dated by the nurse coordinating the assessment (section 45.a and 45.b).

3. Patient #35's record lacked documentation of the reason for and the efficacy of an as needed pain medication for 12 of 21 times the medication was administered.

4. The above records were reviewed with staff member M, the swing bed manager, on 10/28/10 at 10:00 a.m. She verified the above information was missing from the medical records.

Based on document review and staff interviews, the facility failed to conduct or arrange for the required annual total program evaluation. Findings include:

The Conditions of Participation for Program Evaluation were not met in that;

1. The facility failed to complete or arrange for the required annual program evaluation to be completed for the years 2008 and 2009. Refer to C-0331.

2. The facility failed to ensure that the evaluation included the utilization of all CAH services including at least the number of patients seen and the volume of services provided. Refer to C-0332.

3. The facility failed to ensure that the evaluation included a representative sample of both open and closed records. Refer to C-0333.

4. The facility failed to ensure that the purpose of the evaluation determined that the utilization of the CAH services was appropriate, established policies were followed, and if any changes were needed. Refer to C-0335.

5. The facility failed to ensure that the CAH had an effective quality assurance program that evaluated the quality and appropriateness of the diagnosis and treatment provided. Refer to C-0336.

6. The facility failed to ensure that the Quality Assurance program ensured that all patient care and other services were evaluated. Refer to C-0337.

7. The facility failed to ensure that the quality and appropriateness of the diagnosis and treatment provided by the MD or DO were evaluated by an outside hospital, QIO, or other entity. Refer to C-0340.

8. The facility failed to ensure that the staff of the CAH considered the findings or recommendations of the evaluations of the QIO or outside entity and took corrective action, if necessary. Refer to C-0341.

9. The facility failed to ensure that the CAH took appropriate remedial actions to correct the deficiencies identified. Refer to C-0342.

10. The facility failed to ensure that the CAH QA program evaluation documented the outcomes of all of the remedial actions taken. Refer to C-0343.

Based on document review and staff interviews, the facility failed to carry out, or arrange for, an annual evaluation of the total CAH program. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan and the most recent annual CAH program evaluation. The survey team reminded the administrative team of the request for the documentation of the annual program evaluation again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m. The survey team received a copy of the QA plan on 10/28/10 at 9:30 a.m. The facility staff did not provide a copy of, or evidence of, the total program evaluation for the years 2008 and 2009 to the survey team as of the time of the exit conference at 1:00 p.m. on 10/28/10.

On 10/26/10 at approximately 4:00 p.m., during the review of the facility governing body minutes for the preceding two years (2008 and 2009), the surveyor was unable to locate documentation or evidence of a total program evaluation completed for those years.

In an interview with staff member K, medical staff secretary, on 10/27/10 at 3:40 p.m., staff member K stated that there had been no total program evaluation completed in 2009 and was not sure that the evaluation was done in 2008.

Based on document review and staff interviews, the facility failed to carry out or arrange for an annual evaluation of the total CAH program that included at least the number of patients served and the volume of services. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan and the most recent annual CAH program evaluation that included the number of patients served and the volume of services. The survey team reminded the administrative team of the request for the documentation of the annual program evaluation again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m. The survey team received a copy of the QA plan on 10/28/10 at 9:30 a.m. The facility staff did not provide a copy of, or evidence of the program evaluation to the survey team as of the time of the exit conference at 1:00 p.m. on 10/28/10.

On 10/26/10 at approximately 4:00 p.m., during the review of the facility governing body minutes for the preceding two years (2008 and 2009), the surveyor was unable to locate documentation or evidence that a total program evaluation had been completed for those years that included at least the number of patients served and the volume of services provided.

In an interview with staff member K, the medical secretary, on 10/27/10 at 3:40 p.m., staff member K stated that there had been no total program evaluation completed in 2009 and was not sure that the evaluation was done in 2008.

Based on document review and staff interviews, the facility failed to carry out or arrange for an annual evaluation of the total CAH program that included the review of both open and closed records. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan and the most recent annual CAH program evaluation that included a representative sample of both active and closed clinical records. The survey team reminded the administrative team of the request for the documentation of the annual program evaluation again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m. The facility staff did not provide a copy of, or evidence of, the total program evaluation that included the review of both open and closed records to the survey team as of the time of the exit conference at 1:00 p.m. on 10/28/10.

On 10/26/10 at approximately 4:00 p.m., during the review of the facility governing body minutes for the preceding two years (2008 and 2009), the surveyor was unable to locate documentation or evidence of a total program evaluation that included the review of both open and closed records completed for those years.

In an interview with staff member K, medical staff secretary, on 10/27/10 at 3:40 p.m., staff member K stated that there had been no total program evaluation completed in 2009 and was not sure that the evaluation was done in 2008.

Based on document review and staff interviews, the facility failed to carry out or arrange for an annual evaluation of the total CAH program that included in the evaluation whether the utilization of services was appropriate, the established policies were followed, and any changes are needed. Findings include:

During the entrance conference with staff member F, the acting CEO, on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan and the most recent annual CAH program evaluation. This evaluation should have included whether the utilization of services was appropriate, the established policies were followed, and any changes that were needed. The survey team reminded the administrative team of the request for the documentation of the annual program evaluation again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m. The facility staff did not provide a copy of, or evidence of, the total program evaluation that included in the evaluation, whether the utilization of services was appropriate, the established facility policies were followed, and if any changes were needed, to the survey team as of the time of the exit conference at 1:00 p.m. on 10/28/10.

On 10/26/10 at approximately 4:00 p.m., during the review of the facility governing body minutes for the preceding two years (2008 and 2009), the surveyor was unable to locate documentation or evidence of a total program evaluation completed for those years that included the required elements of appropriate utilization of services, that established policies were followed, or if any changes were needed.

In an interview with staff member K, medical staff secretary, on 10/27/10 at 3:40 p.m., staff member K stated that there had been no total program evaluation completed in 2009 and was not sure that the evaluation was done in 2008.

Based on document review and staff interview, the facility failed to create and maintain an effective quality assurance program to evaluate the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan that included the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

The survey team received a copy of the current QA plan on 10/28/10 at approximately 9:30 a.m. There was no documentation of;
- Ongoing monitoring and data collection;
- Problem prevention, identification and data analysis;
- Identification of corrective actions;
- Implementation of corrective actions;
- Evaluation of corrective actions; and
- Measures to improve quality on a continuous basis.
There were no QA committee meeting minutes to review, or reports from the facility departments.

Staff member B, the laboratory director, was interviewed at 9:30 a.m. on 10/28/10. Staff member B stated that there was no real QA committee, and QA activities had been minimally carried out by some department heads.



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On 10/27/10 at 2:30 p.m., staff member B stated the facility had met with the Montana Hospital Association and Mountain Pacific Quality Health to assist with quality assurance. She stated that most of the hospital departments have been submitting quarterly reports to staff member B. There was not a formalized QA Committee. QA was discussed at the department head meetings. She stated QA data was provided to the administrator, but she could not verify that it was presented to the Medical Staff. Staff member B stated she was responsible for patient services.

Based on document review and staff interview, the facility failed to create and maintain an effective quality assurance program that ensured that all patient care services and other services affecting patient health and safety are evaluated. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan. This QA plan should have included an evaluation of the quality and appropriateness of the diagnosis and treatment furnished in the CAH and of the treatment outcomes and that all patient care services and other services affecting patient health and safety were evaluated. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

The survey team received a copy of the current QA plan on 10/28/10 at approximately 9:30 a.m. There was no documentation that all patient care services and other services affecting patient health and safety were evaluated.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety.

In an interview with staff member B, the laboratory director, at approximately 9:30 a.m. on 10/28/10, staff member B stated that there was no real QA committee, and QA activities had been minimally carried out by some department heads.

Based on document review and staff interview, the facility failed to ensure that the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH were evaluated by a QIO or equivalent entity or another appropriate and qualified entity identified in the State rural health care plan. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan. This included that the quality and appropriateness of the diagnosis and treatment furnished by doctors of medicine or osteopathy at the CAH are evaluated by (i) one hospital that is a member of the network, when applicable; (ii) one QIO or equivalent entity; or (iii) one other appropriate and qualified entity identified in the State rural health care plan. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

There were no QA committee meeting minutes to review, or reports from the facility departments. There was no documentation provided by the facility that these activities were evaluated by a QIO or other appropriate and qualified entity.

In an interview with staff member B, the laboratory director, at approximately 9:30 a.m. on 10/28/10, staff member B stated that there was no real QA committee, and QA activities had been minimally carried out by some department heads.

Based on document review and staff interview, the facility failed to ensure that findings of the evaluations, including any findings or recommendations of the QIO, and takes corrective action if necessary. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan which included the CAH staff considers the findings of the evaluations and any findings or recommendations by the QIO were considered by the CAH staff, and took corrective action if necessary. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

There were no QA committee meeting minutes to review, or reports from the facility departments. There was no documentation provided by the facility that these activities were evaluated by a QIO or other appropriate and qualified entity or corrective action was taken if necessary of any findings or recommendations.

In an interview with staff member B, the laboratory director, at approximately 9:30 a.m. on 10/28/10, staff member B stated that there was no real QA committee, and QA activities had been minimally carried out by some department heads.

Based on document review and staff interview, the facility failed to take appropriate remedial action to address deficiencies found through the quality assurance program. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan which included documentation that the CAH took appropriate remedial action to address deficiencies found through the quality assurance program. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

The survey team received a copy of the current QA plan on 10/28/10 at approximately 9:30 a.m. There was no documentation that all patient care services and other services affecting patient health and safety were evaluated.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety. There was no documentation that remedial actions were taken to address deficiencies identified in the quality assurance program. There was no documentation indicating the individual responsible for implementing remedial actions to correct deficiencies identified by the quality assurance program.

In an interview with staff member B, the laboratory director, at approximately 9:30 a.m. on 10/28/10, staff member B stated that there was no real QA committee, and QA activities had been minimally carried out by some department heads

Based on document review and staff interview, the facility failed to document the outcomes of quality assurance remedial action. Findings include:

During the entrance conference with staff member F, the acting CEO (chief executive officer), on 10/25/10 at 10:30 a.m., the survey team provided staff member F with a list of requested documents and information that included a copy of the facility Quality Assurance (QA) plan which included documentation of the outcome of all remedial action. The survey team reminded the administrative team of the request for the documentation of the QA plan again at the end of day meeting on 10/27/10 that began at 4:30 p.m. The surveyor repeated the request to staff member F on 10/28/10 at approximately 8:30 a.m.

The survey team received a copy of the current QA plan on 10/28/10 at approximately 9:30 a.m. There was no documentation that all patient care services and other services affecting patient health and safety were evaluated.

There were no QA committee meeting minutes to review, or reports from the facility departments covering the evaluation of all patient care services and other services affecting patient health and safety. There was no documentation of the outcomes of any remedial action.

On 10/27/10 at 2:30 p.m., staff member B, the laboratory director, stated that most of the hospital departments have been submitting quarterly reports to her. There was not a formalized QA Committee. QA was discussed at the department head meetings.

Based on policy review, record review, and staff and resident interview, the facility failed to provide for an ongoing program of activities, directed by a qualified professional, designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being for 4 (#s 34, 35, 36 and 37) of 4 sampled swing bed residents. Findings include:

1. The Social Services and Activities for Swing Bed Patients Policy #: SWNGBD.0010, revised 4/2010, read, "Purpose: To assure provision of social services and activities to swing bed patients. Policy: A patient's psychosocial needs will be assessed via the admission assessment of the social worker, the medical history, interview with the patient and family, and information from referring agencies. The assessments will include, but are not restricted to:
1. The presence of advance directives
2. The patient's ability to communicate
3. Their living situation and support group
4. The use of community resources
4. Usual activities, hobbies, likes and dislikes.
6. The patient's general health status, and any other conflicts or concerns the patient identifies.
7. Discharge plans.

Psychosocial problem will be identified on the Care Plan as described in charting and care planning policies. Outside activities will be offered by Social Services in conjunction with activities offered by Glacier Care Center, in mutual agreement. Referral to social services can be done through the admission assessment notification, e-mail, or by direct contact."

2. Patient #34, was admitted to the swing bed unit on 10/19/10. Diagnoses included depression, anxiety, chronic pain emphysema, and chronic obstructive pulmonary disease. The medical record lacked an assessment or care plan for activities.

3. On 10/25/10 at 2:05 p.m., staff member S, CNA, stated, "No one here does activities."

On 10/25/10 at 2:50 p.m., staff member M, swing bed manager, stated, "Social services makes an activities assessment. The CNAs are to offer activities daily."

On 10/26/10 at 10:45 a.m., staff member M, swing bed manager, stated there should be an activity calendar posted in patient #34's room or on the bulletin board by the nursing station. This calendar should be posted monthly. Staff member M provided a Swing Bed Activity Log for patient #34. This Activity Log indicated the resident likes were "watching TV and playing cards." This form included space for staff to document the activity offered, accepted or declined with the date and the time spent with the activity. Resident #34's activity log indicated the following: 10/24/10 and 10/25/10, the patient accepted "Walking in the Halls" for 10 minutes. On 10/25/10, the patient declined playing cards.

On 10/26/10 at 1:00 p.m., patient #34, the only swing bed patient currently in residence at the CAH, stated he was not aware of any activities offered at the CAH. There was not an activities calendar posted in patient #34's room.

On 10/26/10 at 1:15 p.m., the bulletin board outside the nursing station was observed. There was a section titled Activities. There was not an activities calendar posted.

On 10/26/10 at 1:40 p.m., the Social Services Designee Job Description was reviewed. The Description of Duties included, "Assess the psychosocial needs of the resident." At this time, staff member K, Human Resource Manager, stated, "The social worker has a social service degree. She has had no experience with activities."

On 10/26/10 at 1:55 p.m., the administrator at Glacier Care Center was interviewed by telephone. She stated she was not aware of any agreement for swing bed patients from the CAH to participate in activities at Glacier Care Center. To her knowledge, there had never been any swing bed patients participating in activities at Glacier Care Center.

On 10/26/10 at 2:00 p.m., the activities director at Glacier Care Center was interviewed by telephone. She stated that if the CAH requested an activity calendar, she would provide one to the CAH. In the three years since she had worked at Glacier Care Center, she remembered one swing bed patient participating in one activity.

Patient #s 34, 35, 36, and 37 medical records lacked activity assessments and a care plan that addressed activities.

The facility failed to provide a qualified therapeutic recreation specialist or an activities professional who would provide for an ongoing program of activities for swing bed patients.

Based on staff interview and medical record review, the facility failed to provide a comprehensive assessment of nutritional needs for 4 (#s 34, 35, 36, and 37) of 4 sampled swing bed residents. Findings include:

On 10/25/10 at 2:05 p.m., staff member M, swing bed manager, stated the dietitian resigned 3-4 months ago. There was not a signed current contract with a dietitian. She stated the facility has a contract with Glacier Care Center to provide meals.

Review of resident #'s 34, 35, 36, and 37 medical records, lacked documentation of an assessment by a registered dietitian.

Based on record review and staff interview, the facility failed to provide therapeutic diets when there was a nutritional problem for 3 (#s 35, 36, and 37) of 4 sampled swing bed residents. Findings include:

1. On 10/25/10 at 4:00 p.m., the dietary manager at Glacier Care Center stated the facility provided three types of diets which included, controlled carbohydrate 1800 calorie ADA (American Dietetic Association), a renal diet, and a cardiac diet. For an ordered 2 gram sodium diet and low fat, low cholesterol diet, the strictest of the three above listed diets was provided.

2. Resident #35 was admitted to the facility on 7/10/10 with diagnoses including, paraplegia, stage IV decubitus ulcer, diabetes, chronic obstructive pulmonary disease, osteomyelitis, and rheumatoid arthritis. The medical record lacked a nutritional assessment. The physician ordered a 1500 calorie ADA diet. A 1500 calorie ADA diet was not a diet that was offered by Glacier Care Center. According to the Nutrition Care of the Older Adult, Second Edition dated 2004, page 194 read, "A nutrition assessment of the older adult should include a physical assessment of the condition of the skin. The older adult is at risk for the development of pressure ulcers based on multiple risk factors, including physical limitations, disease conditions, and medical treatments.... The dietetics professional should be an active participant on the wound care team that monitors healing and recommends protocol changes to advance the healing process. Frequent and detailed documentation in the medical record should support nutrition interventions recommended."

3. Resident #36 was admitted to the facility on 10/7/10 with diagnoses including congestive heart failure, macular degeneration, and valvular heart disease. The medical record lacked a nutritional assessment. The physician ordered a 2 gram sodium 1500 fluid restriction diet. A 2 gram sodium 1500 fluid restriction diet was not a diet that was offered by Glacier Care Center. A 10/13/10 Nurse's Notes, at 6:45 a.m., read, "Refused Lasix initially but was eating ham for bkft [breakfast] therefore talked pt [patient] into taking it." According to the Manual of Clinical Dietetics Sixth Edition dated 2000, Guidelines for Food Selection for a 2 gram sodium diet, excluded or limited items included any smoked, cured, salted, koshered, or canned meat, fish, or poultry including bacon, chipped beef, cold cuts, ham..."

4. Resident #37 was admitted to the facility on 10/1/10 with diagnosis including anxiety, chronic obstructive pulmonary disease, and stage IV decubitus ulcer. The medical record lacked a nutritional assessment and a diet order by the physician. According to the Nutrition Care of the Older Adult, Second Edition dated 2004, page 194 read, "A nutrition assessment of the older adult should include a physical assessment of the condition of the skin. The older adult is at risk for the development of pressure ulcers based on multiple risk factors, including physical limitations, disease conditions, and medical treatments.... The dietetics professional should be an active participant on the wound care team that monitors healing and recommends protocol changes to advance the healing process. Frequent and detailed documentation in the medical record should support nutrition interventions recommended."