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Based on record review and interview, the facility failed to include documentation, in the patient's medical record, that a written notice of the CAHs policy regarding the formulation of an advance directive was provided to patients upon admission. The facility failed to include documentation in the patient's medical record that reflected patients were notified in a clear and precise statement of limitation if the CAH could not implement an advanced directive. This affected 20 out of 20 sampled patients. This has the potential to affect all patients admitted to the facility for inpatient and outpatient care. Findings include:

1. A record review, of the 20 sampled patients' medical records, did not reflect documentation of written notification of the facility's policy regarding information for formulating an advanced directive. The medical record did not reflect documentation that sampled patients received a clear and concise statement of limitation if the CAH could not implement an advance directive.

Review of the facility form titled, Patient Registration, reflected a check off section. The heading of the check off section reflected, "Montana Advanced Directive Registry awareness program." Below the heading, was a check off that reflected, "Yes, I have filed an Advanced Directive with the EOL Registry, [or] No, I have not filed..." The registration form did not reflect an area for patients to sign to acknowledge that they had received a notice about their rights to formulate an advanced directive.

During an interview on 4/6/17 at 3:08 p.m., staff member A stated patients are given the end of life registry form to formulate advanced directives. Staff member A stated the form is not a facility form, and the staff makes a copy each time one is needed. The facility admission packet did not include the life registry form. Staff member A stated the facility has rarely used the form. Staff member A stated most patients decline information to formulate an advanced directive. None of the sampled medical records reflected the form or acknowledgement it was offered.

Review of the facility policy and procedure titled, "Advanced Directives and Health Care Decision Making", did not reflect a procedure to use the Montana End of Life Registry form. The policy reflected the social service staff member would provide the patient with information regarding their rights to establish a Living Will, and would encourage the patient to carefully consider the information and forms provided.

Based on interview, review of the patient medical record, and review of the facility policies and procedures, the facility failed to ensure there was a written plan for the infection control program (C-278), failed to ensure staff wore personal protective clothing during cleaning of dental instruments (C-278), failed to provide preventative maintenance annually for the portable X-ray machine (C-283), failed to maintain a list of all services furnished under arrangement or agreement (C-291), failed to have a written policy for verbal orders that included; situations in which verbal orders could be used as well as limitations, list of elements required for inclusion in the verbal order process, established protocols for clear and effective communication to include verification of verbal orders (read back), and procedures to identify the categories of clinical staff who are authorized to receive and act upon a verbal order (C-297), and failed to revise patient care plans, and update each care plan with changes as needed (C-298).

The cumulative effect of the failed standards resulted in the facility not having updated and comprehensive patient care policies. This failure caused an inability to provide consistent care and monitoring of the services provided, to include services through contract and/or agreement.

Based on record review and interview, the facility failed to ensure there was a written plan for the infection control program, and failed to ensure staff wore personal protective clothing during cleaning of dental instruments. Findings include:

1. Review of the facility's Infection Control policies and procedures did not show a facility wide, written plan, to identify, report, investigate and control infections and communicable diseases of patients and personnel. The infection control program did not show the facility monitored staff for compliance with infection control requirements and any corrective action taken.

During an interview on 4/6/17 at 3:55 p.m., staff member B stated the infection control training for staff included an annual in-service on blood borne pathogens. Staff member B stated staff were educated on an individual basis. Staff member B did not provide evidence the facility monitored staff for compliance with infection control practices. Staff member B stated most of the infection control monitoring was being done with the Nurse Aide Training Program. Staff member B stated observation of medication pass is part of the infection control program, but had not been started.

Review of the Summary of Infection Control, for 2016, did not show monitoring of staff, patient or family education, or a written plan to prevent and/or control the spread of infections and communicable diseases. The Summary of Infection Control, for 2016, identified infections for each month, however did not show ongoing monitoring, investigation and education of hospital acquired infections.

Review of the facility's infection control policies did not show role-specific education/training for limiting the spread of infections.

During an interview on 4/6/17 at 4:05 p.m., staff member B stated observations were made in the halls and education was part of the staff evaluations. Staff member B did not provide documentation of education for dietary, housekeeping, laundry or other departments within the CAH. Staff member B stated the QA project included monitoring of hand washing, and proper disposal, however did not provide requested documentation of ongoing monitoring and education.

2. During an interview on 4/6/17 at 10:00 a.m., staff member E stated she was responsible for cleaning the dental instruments. Staff member E stated she takes the instruments to the autoclave room. Staff member E stated the dental instruments are placed in the sink and cleaned using a scrub brush. Staff member E stated she did not wear protective clothing or eye protection during the scrubbing process. Staff member E stated she was not trained to wear protective equipment during the instrument cleaning process.

During an observation of the autoclave room, on 4/6/17 at 9:45 a.m., there were no non-permeable aprons or goggles available for staff use when cleaning instruments used for medical procedures.

Based on record review and interview, the facility failed to provide preventative maintenance annually for the portable X-ray machine. This has the potential to affect all patients receiving X-ray services using the portable X-ray machine. Findings include:

1. Review of a service report, for the portable X-ray machine, reflected an annual preventative maintenance was performed on 4/17/15.

During an observation and interview on 4/4/17 at 3:45 p.m., staff member D stated the facility did not use the portable X-ray in 2016. Staff member D stated the portable X-ray machine did not have preventative maintenance completed in 2016. Staff member D stated the facility had not retired the machine out of service. The portable X-ray machine was observed to be in the X-ray room sitting next to the other fixed X-ray machine.

On 4/6/17 staff member D submitted a letter that reflected the portable X-ray machine would have a preventative maintenance completed on 4/11/17.

Based on record review and interview, the facility failed to maintain a list of all services furnished under arrangement or agreement. This has the potential to affect all patients receiving care and services in the facility. Findings include:

1. The facility submitted, to the survey team, a stack of loose service contracts. The facility did not submit a list of the patient care services furnished through arrangement or agreements.

During an interview on 4/4/17 at 2:30 p.m., staff member A stated the facility did not have a list of their contracts and agreements. Staff member A stated she could make one for the survey team.

Review of a form, in the facility surveyor binder, reflected a list of contracted service providers, for the facility, dated 9/19/13. The list did not reflect what service(s) was being provided, if it was offered on or off site, if there was a limit on the volume or frequency of the service(s) provided, and when the service(s) would be available.

Review of the facility policy titled, Agreements or Arrangements, reflected services were to be routinely assessed by the Quality and Service committee annually. The last revision date on the policy was 8/27/14.

Based on record review and interview, the facility failed to have a written policy for verbal orders that included; situations in which verbal orders could be used as well as limitations, list of elements required for inclusion in the verbal order process, established protocols for clear and effective communication to include verification of verbal orders (read back), and procedures to identify the categories of clinical staff who are authorized to receive and act upon a verbal order. This has the potential to affect all patients receiving care and services at the facility. Findings include:

1. A record review of the facility policy and procedure for verbal orders did not include the minimum requirements as listed above.

During an interview on 4/6/17 at 9:40 a.m., staff member A stated the current policy for verbal orders was the facility policy.

Based on record review and interview, the facility failed to revise patient care plans, and update each care plan with changes as needed for 10 (#s 1, 2, 3, 4, 5, 6, 7, 8, 9, 10) acute care patients out of 20 sampled. This has the potential to affect all patients admitted to the facility. Findings include:

Review of the medical record, for all sampled patients, did not reflect documentation that reflected the care plan had been reviewed or revised.

During an interview on 4/6/17 at 2:00 p.m., staff member A stated the nursing staff writes nurses notes for changes in the patient's condition, or concerns for each patient as needed. Staff member A stated the nursing staff complete a monthly assessment that is kept in the chart. Staff member A stated the nursing staff does not enter changes on the initial care plan.

Based on record review and interview, the facility failed to have a complete, accurate, and readily accessible medical record for 10 (#s 1, 2, 3, 4, 5, 6, 8, 9, 10 and 12) out of 20 sampled patients. Findings include:

1. Review of patient #1's medical record reflected the advanced directive area on his Registration form was blank. Review of the COBRA transfer form reflected the Mode of Transport was blank, and the Accompanying Documentation check off was blank. The Accompanying Documentation check off did not reflect his medical records were sent to the facility where he was transferred.

2. Review of patient #2's medical record did not include documentation that he received written notice of his patient rights, and information for how to file a grievance or complaint.

3. Review of patient #3's medical record did not include documentation that she received written notice of her patient rights, and information for how to file a grievance or complaint.

4. Review of patient #4's medical record did not include documentation that she received written notice of his patient rights, and information for how to file a grievance or complaint.

5. Review of patient #5's medical record reflected the advanced directive area on his registration form was blank. The medical record did not reflect he was given information for how to file a grievance or complaint.

6. Review of patient #6's medical record did not reflect he was given information for how to file a grievance or complaint.

7. Review of patient #8's medical record did not reflect an OPO form. The medical record did not reflect he was given information for how to file a grievance or complaint.

During an interview on 4/6/17 at 1:45 p.m., staff member A stated the OPO form must have gone with the patient to the funeral home. On 4/7/17 a fax was received from the facility that reported the form was shredded.

8. Review of resident #9's medical record did not reflect she was given information for how to file a grievance or complaint.

9. Review of resident #10's medical record reflected the advanced directive area on his registration form was blank. The medical record did not reflect he was given information for how to file a grievance or complaint.

10. Review of patient #12's medical record did not reflect she was given information for how to file a grievance or complaint. The medical record did not reflect a comprehensive nurse admission assessment.

During an interview on 4/6/17 at 9:40 a.m., staff member A stated the maintenance supervisor would have to go to storage to retrieve the nurse admission assessment record.

Based on record review and interview, the facility failed to conduct, and document a periodic evaluation of the total QA program (C-331), failed to evaluate health care policies annually (C-334), and failed to have a hospital-wide QA program (C-336).

The cumulative effect of the failed standards resulted in the facility not having a comprehensive measurement of the quality of care and services provided to patients. This did not allow for the facility to be able to ensure all departments were actively participating in the QA process, to include services provided through contract and/or agreement.

Based on record review and interview, the facility failed to conduct, and document a periodic evaluation of the total QA program. Findings include:

1. On 4/3/17 a written request was submitted to staff member A and B for a copy of the current quality assurance plan, and the most recent annual CAH program evaluation.

During an interview on 4/3/17 at 4:45 p.m., staff member A stated the facility had a consultant, but did not have one presently for QA recommendations.

A written request was submitted on 4/4/17 for documentation that reflected an evaluation of the facility's total QA program.

During an interview on 4/4/17 at 2:40 p.m., staff member A stated the facility did not have a formal format that documented the total QA program evaluation.

On 4/4/17 staff member A submitted a two page letter titled, "Annual Review for Quality Assurance." The letter was a generalized summary for department projects, but did not reflect a formal plan, or evaluation of the plan.

A review of the department QA projects reflected the emergency department, radiology, pharmacy, OPO, and infection control did not have a QA project plan, or evaluation of the plan for the year 2016.

Review of the facility policy and procedure, titled Quality Assurance Quality Improvement Plan, reflected the purpose of the plan. The purpose showed the facility was to provide a structured, accountable approach for both the monitoring of, and improvement of quality of care and patient safety, in all entities of the medical center. Elements of the plan included the formation of focus groups designed to monitor and implement improvement(s). The focus groups were to utilize tools to analyze problems, and achieve quality improvement goals and objectives. Five focus groups were listed with who was to be a member of the group, how often the group would meet, and very specific focus areas for each one. This process was not reflected in the information provided by the facility in the Annual Review for Quality Assurance letter.

No written documentation was submitted prior to exit that reflected an evaluation of the total QA program was completed.

Based on record review and interview, the facility failed to evaluate health care policies annually. Findings include:

1. Review of the facility policy and procedure manual reflected several departmental health care policies that had not been reviewed, revised, or approved annually.

Several different documents were reviewed to obtain an accurate record of the dates, with the appropriate signatures, for all departments of the hospital to include; the policy and procedure manual, the policy and procedure committee meeting minutes, the department head meeting minutes, the governing body meeting minutes, and the policy review signature sheets.

The facility did not have a consistent system for the review and approval of the health care policies and procedures.

The following health care policies and procedures reflected documentation of dates reviewed, and completed signature approval by the department head and the medical director as follows:

administration 8/5/15
business office 6/10/15
central supply 9/16/14
emergency department 9/14/15 (no medical director signature)
pharmacy 8/5/14
physical therapy 4/21/15

During an interview on 4/3/17 at 3:00 p.m., staff member A stated the policy and procedure manual should contain the current annual reviews, with the signatures of approval. Staff member A stated she would ask staff member B to provide the current facility policies and procedures.

During an interview on 4/3/17 at 3:15 p.m., staff member B stated the facility changed their system to a different form. Staff member B stated the reviews were not entered by the IT staff for one year.

Based on record review and interview, the facility failed to have a hospital-wide QA program. Findings include:

On 4/3/17, a written request was submitted to staff member A and B for a copy of the current quality assurance plan, and the most recent annual CAH program evaluation.

On 4/4/17 staff member A submitted a two page letter titled, "Annual Review for Quality Assurance." The letter was a generalized summary for department projects, but did not reflect a formal plan, or evaluation of the plan.

A review of the department QA projects reflected the emergency department, radiology, pharmacy, OPO, and infection control did not have a QA project plan, or evaluation of the plan for the year 2016.

During an interview on 4/6/17, staff member A stated the emergency room kept a log for checking the crash cart. This was not included in the QA review. Staff member A did not submit a formalized plan for the QA project of keeping this log for the crash cart.

During an interview on 4/5/17, staff member D stated the radiology QA project was documenting the dosimetry for the employee radiology badges, and testing the aprons annually. Staff member A did not submit a formalized plan for the QA project of monitoring staff dosimetry badges, or the aprons used to shield patients.

No written documentation was submitted prior to exit that reflected all departments participated in the annual QA program for the departments listed above.

Based on record review and interview, the facility failed to designate a requestor for the OPO responsibilities to approach family with requests for organ donations. This has the potential to affect all patients requiring OPO services. Findings include:

Review of the facility's agreement with the organ recovery center reflected the facility would ensure that the family of each potential donor would be advised of donor designation or donation options only by a representative of the organ recovery center or a designated requestor.

During an interview on 4/6/17 at 10:05 a.m., staff member A stated the facility did not have a designated requestor. Staff member A stated it is usually whoever is on duty. Staff member A stated training is done on orientation.

Based on record review and interview, the facility failed to include all patient rights, in the facility notification, of patient rights. The facility patient rights notification did not include: the right to work or not work, retain and use personal possessions, have access to their medical record, choose their MD/DO, refuse treatment, and receive in writing information to assist them in formulating an advanced directive for 10 (#s 11, 12, 13, 14, 15, 16, 17, 18, 19, and 20) out of 20 sampled residents. Findings include:

1. Review of the 10 sampled patients' medical charts reflected a signed document titled Resident Rights. The document did not include; the right to work or not work, retain and use personal possessions, have access to their medical record, choose their MD/DO, refuse treatment, and receive in writing information to assist them in formulating an advanced directive.

During an interview on 4/6/17 at 3:30 p.m., staff member A stated the facility resident rights notification followed the regulation language. Staff member A stated perhaps the regulations had changed, and the form was not updated.

Based on record review and interview, the facility failed to complete a comprehensive admission assessment outlining the needs and functional capabilities for all swing bed patients for 10 (#s 11, 12, 13, 14, 15, 16, 17, 18, 19 and 20) of 20 sampled patients. This has the potential to affect current and future swing bed patients. Findings include:

1. Review of the medical records for all swing bed patients did not reflect a completed comprehensive admission assessment.

On 4/5/17 a request was made to the facility for copies of admission assessments and admission nursing progress notes for all swing bed patients. At the time of the exit conference, the facility failed to provide requested copies.

During an interview on 4/6/17 at 3:30 p.m., staff member A stated the admission assessments had been thinned from the charts and the maintenance supervisor would have to retrieve the records.

Based on record review and interview, the facility failed to revise patient care plans, and update each care plan with changes as needed for 10 (#s 11, 12, 13, 14, 15, 16, 17, 18, 19, 20) swing bed patients out of 20 sampled. This has the potential to affect all swing bed patients admitted to the facility. Findings include:

Review of the medical record, for all swing bed patients, did not reflect documentation that reflected the care plan had been reviewed or revised.

During an interview on 4/6/17 at 2:00 p.m., staff member A stated the nursing staff writes nurses notes for changes in the patient's condition, or concerns for each patient as needed. Staff member A stated the nursing staff complete a monthly assessment that is kept in the chart. Staff member A stated the nursing staff does not enter changes on the initial care plan.

Based on record review and interview, the facility failed to provide or obtain routine dental services for 4 swing bed patients (#s 11, 16, 18 and 19) of 20 sampled patients. This has the potential to affect current and future swing bed residents. Findings include:

1. Resident #11 was admitted on 11/6/06. Review of the medical record did not show evidence of dental services.

2. Resident # 16 was admitted on 3/2/16. Review of the medical record did not show evidence of dental services.

3. Resident #18 was admitted on 10/27/15. Review of the medical record did not show evidence of dental services.

4. Resident #19 was admitted on 10/2/13. Review of the medical record did not show evidence of dental services.

On 4/6/17 a request was made to the facility for documentation of dental services for the four sampled patients. At the time of exit, the facility had not provided the requested documentation.

On 4/16/17 at 4:15 p.m., staff member A stated the facility had on-site dental services, but could not find documentation of dental services for patient #s 11, 16, 18 and 19.

Based on record review and interview, the facility failed to have a visitation policy and procedure that did not restrict, limit, or deny visitation privileges, and that ensured all visitors enjoyed full and equal visitation privileges consistent with patient preference. Findings include:

1. Review of the facility visitation policy, with a revision date of 11/11/15, reflected, "1. Only immediate family may enter a patients room. 3. Patient visits with friends will be conducted in common areas of the facility unless we have written consent from the DPOA or the patient. ie TV room, dining area and activities room."

During an interview on 4/6/17 at 9:40 a.m., staff member A stated this was the current policy in use for visitation for all patients at the facility. Staff member A stated patient visits are conducted outside of the patient room, when the patient has a roommate, without asking what the patient preferred.