HospitalInspections.org

Based on interview and record review, the facility failed to ensure staff had current certifications required to care for patients in the emergency department. This deficient practice had the potential to affect the quality of care for all patients who received care in the emergency department. Findings include:

Review of staff member C's personnel record showed she was a contracted staff with the facility on 7/2/24. Staff member C worked in the emergency department. Staff member C did not have a current PALS (Pediatric Advanced Life Support) certification and review of her personnel file showed her PALS certification had expired in 6/2024.

Review of staff member S's personnel record showed she was hired on 12/22/22. Staff member S worked in the emergency department. Staff member S did not have an ACLS (Advanced Cardiac Life Support) certification on file.

During an interview on 7/30/24 at 2:58 p.m., staff member B stated she kept a file with all the licenses and certifications for facility staff.

During an interview on 7/31/24 at 10:01 a.m., staff member B stated she knew there were some staff members who did not have current certifications. Staff member B stated she used a spreadsheet to track when licenses or certifications expired. Staff member B stated she had been working with different facilities to set up a class for staff with expired certifications, but had been, "Struggling to get it done."

Review of a facility document titled, "Job Classification, Registered Nurse," undated showed:

... "Licensure/Certification: State of Montana Nursing license, Certified in ACLS- Advanced Cardiac Life Support, PALS- Pediatric Advanced Life Support ...

... 33. Must maintain and or attain BLS, ACLS, PALS...or other certifications as may be requested or required by [Facility Name] to provide safe quality patient care."

Based on observation, interview, and record review, the facility failed to establish policy and procedures for the safe utilization of space heaters in the facility and failed to ensure FSC was observed while using space heaters in the facility ¹. This deficient practice had the potential to affect all patients and staff utilizing the tub room in the facility. Findings include:

During an observation on 7/29/24 at 2:45 p.m., there was an unplugged Comfort Zone brand space heater observed in the facility's tub room, room number 152. The space heater did not have a thermostat which specified the heating element on the device did not exceed 212 degrees Fahrenheit.

During an interview on 7/30/24 at 12:10 p.m., staff member W stated the space heater should not be in the tub room at all. She stated the space heater may be being brought in by another staff member who feels the tub room does not get warm enough when providing baths for patients.

During an interview and record review on 7/30/24 at 12:10 p.m., a facility document request was submitted for the policy and procedure for space heater use in the facility. Staff member W stated the facility did not have a policy or procedure for the use of space heaters in the facility.

¹ Actual Code: NFPA 101, 2012 Edition, Section 19.7.8: Portable space heating devices are prohibited in health care occupancies. Exception: Portable space-heating devices shall be permitted to be used in non-sleeping staff and employee areas where the heating elements of such devices do not exceed 212 degrees Fahrenheit. If a facility is utilizing space heaters, the facility must maintain documentation/policies consistent with the Life Safety Code.

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Staffing and Staff responsibilities.

Based on interview and record review the facility failed to:

-Ensure the physician in conjunction with the mid-level providers, periodically reviewed patient records. This deficient practice had the potential to affect all patients receiving care in the facility. (See C0985).

- Ensured a Doctor of Medicine or Osteopathy signed the records for all inpatients cared for by Nurse Practitioners or Physician Assistants. This deficient practice had the potential to affect the quality of care for all patients admitted to the facility. (See 0986).

-Ensure a Doctor of Medicine or Osteopathy was available though direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This deficient practice had the potential to affect the quality of care of all patients who sought care at the facility. (See C0988).

-Ensure a process was in place for Nurse Practitioners and Physicians Assistants to notify a Doctor of Medicine or Osteopathy when an inpatient admission occurred. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. (See C998).

-Ensure a process was in place for periodic performance evaluations of Nurse Practitioners and Physician Assistants by a Doctor of medicine or Osteopathy. This deficient practice had to the potential to affect all patients receiving care in the facility by a Nurse Practitioner or Physician Assistant. (See C0999).

Based on interview and record review, the facility failed to ensure the physician in conjunction with the mid-level providers, periodically reviewed patient records. This deficient practice had the potential to affect all patients receiving care in the facility. Findings include:

During an interview on 7/31/24 at 10:00 a.m., staff member H stated she had only been working at the facility since March of 2024. Staff member H stated, "I don't know what the process for periodic review of patient records is, I just started looking at them." (Patient Records).

Review of a facility document titled, "Medical Staff Rules and Regulations," with a revision date of 11/20/24, showed:
... "9. Physician Review. The supervising Physician must review and sign the records of each patient admitted and treated by a Physician Assistant or Nurse Practitioner...".

Review of a facility document titled, "Medical Director/Chief of Staff Overview," undated, showed:
... "a. In conjunction with ... physician assistants and or APRN's, periodically review the Hospital's patient records, ..." [sic]

Based on interview and record review the facility failed to have a process which ensured a Doctor of Medicine or Osteopathy signed the records for all inpatients cared for by Nurse Practitioners or Physician Assistants. This deficient practice had the potential to affect the quality of care for all patients admitted to the facility. Findings include:

During an interview on 7/31/24 at 10:00 a.m., Staff member H stated she had not been reviewing inpatient records of patients who were admitted by Nurse Practitioners or Physician Assistants. Staff member H stated, "I am supposed to, but I have not done it yet."

Review of a facility document titled, "[Facility Name] Medical Staff Bylaws," dated October 2023, showed:
... "C. Medical Direction and Oversight...
... b. ...reviews and signs the records ... of each inpatient admitted and treated in the Hospital by APRN's and PA's ..."

Based on interview and record review, the facility failed to ensure a Doctor of Medicine or Osteopathy was available through direct radio or telephone communication or electronic communication for consultation, assistance with medical emergencies, or patient referral. This deficient practice had the potential to affect the quality of care of all patients who received care at the facility. Findings include:

During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was the facility physician who was available at all times. Staff member H stated she was on-call 24 hours a day, seven days a week, unless she was out of service. Staff member H stated there was no alternate physician coverage if she was, "Out of range."

Review of a facility document titled, "[Facility Name] Medical Staff Bylaws," dated October 2023, showed:
... "C. Medical Direction and Oversight
1. The Medical staff shall ensure that a Physician Member at all times is available and responsible to provide medical direction for the Hospital's health care activities ... a Physician member shall be available to provide healthcare services to the patients in the Hospital, wherever needed and requested.
... e. ... and is available by radio, telephone or electronic communication for consultation, assistance with medical emergencies and patient referrals." [sic]

Based on interview and record review, the facility failed to have a process in place to ensure Nurse Practitioners and Physicians Assistants notified a Doctor of Medicine or Osteopathy when an inpatient admission occurred for 6 (#s 7, 11, 14, 15, 18, and 19) of 20 sampled patients. This deficient practice had the potential to affect the quality of care for patients admitted to the facility. Findings include:

During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was not notified of all inpatient admissions and is not sure what the facility process was.

Review of the following medical records failed to show the Nurse Practitioner, or the Physician Assistant, notified the physician of the admission to of a patient to inpatient status.

- Patient #7, admitted on 4/16/24, discharged on 4/18/24,
- Patient #11, admitted on 11/24/23, discharged on 11/24/23,
- Patient #14, admitted on 2/15/24, discharged on 2/21/24,
- Patient # 15, admitted on 7/25/23, discharged on 8/4/24,
- Patient #18, admitted on 8/3/23, discharged on 8/6/23, and
- Patient #19, admitted on 3/5/24, discharged on 3/8/24.

Review of a facility document titled, "Medical Staff Rules and Regulations," with a revision date of 11/20/24, showed:
... "5. Physician Notification. Whenever a patient is admitted to the Hopital by a Physician Assistant or Nurse Practitioner, a supervising Physician must be notified... within 24 hours after the admission and a written notification of the consultation and of the Physician's approval or disapproval must me kept in the patient's record."

Based on interview and record review, the facility failed to ensure a process was in place for periodic performance evaluations of Nurse Practitioners and Physician Assistants by a Doctor of Medicine or Osteopathy. This deficient practice had to the potential to affect all patients receiving care in the facility by a Nurse Practitioner or Physician Assistant. Findings include:

Review of a credentialing file for staff member J showed no periodic reappraisal had been completed.

Review of a credentialing file for staff member N showed no periodic reappraisal had been completed.

During an interview on 7/31/24 at 10:00 a.m., staff member H stated she was not aware of any process for periodic evaluation of clinical privileges and had not done any periodic evaluations of facility Nurse Practitioners and/or Physician Assistants.

Based on observation, interview, and record review, the facility failed to ensure current and accurate records are kept of the receipt and disposition of all scheduled drugs; and failed to develop and implement patient care policies and procedures which addressed the storage, handling, dispensing, and administration of drugs and biologicals with the facility. This deficient practice had the potential to affect all patients receiving pharmaceutical services. Findings include:

1. Accurate Records of Scheduled Drugs

A. Fentanyl Patches

During an observation on 7/30/24 at 9:30 a.m., the narcotic logbook showed a count of nine, 100 mcg Fentanyl patches for patient #4. An observation of the actual package of Fentanyl, which was secured in the lock box, showed a count of four patches. The pharmacy label showed a count of 10 patches; there was only one box of five patches found in the lock box.

During an interview on 7/30/24 at 10:15 a.m., staff member R stated the family had brought in patient #4's Fentanyl patches from home. She stated they only brought in one box of patches which was not opened. Staff member R stated when she logged the patches in with her co-worker, she only looked at the pharmacy label on the box of Fentanyl patches and assumed there were 10 patches in the box since that was what the pharmacy label showed. Staff member R said she did not read the box itself or open the box to count the number of patches. She stated that could explain why the narcotic logbook showed a count of nine patches and the actual count of Fentanyl patches was only four. She stated it was the expectation when logging in a patient's scheduled medications into the logbook there were two nursing staff to verify the count.

B. Liquid Morphine Sulfate

During an observation on 7/30/24 at 9:30 a.m., the Narcotic Log showed Liquid Morphine was available for patient #1. The box which contained the liquid morphine showed two separate labels for two separate patients. The first label was printed from a pharmacy which showed the medication was issued to patient #1. The second label was printed by the facility and was placed on the box of liquid morphine and had patient #4's identifying information listed.

During an interview on 7/30/24 at 10:00 a.m., staff member S stated she had asked another staff member to print her patient identification label for patient #1 so she could put it on the box of morphine for patient #1. Staff member S admitted she did not verify the name on the label she placed on the box of morphine for patient #1 and did not realize that it was a label for patient #4. Staff member S stated it was important to verify the information with a second nurse when logging in new scheduled medications for patients.

During an interview on 7/30/24 at 10:15 a.m., staff members B and I stated it was the expectation that all scheduled medications were logged into the Narcotic Logbook with a double count with a two-nurse verification, and the expectation that the narcotic count would be accurate for what was in the lock box in addition to what was on the Narcotic Log. They stated it was also important that the correct patient identifiers were placed on the appropriate medications.

2. Development and Implementation of Medication Policy and Procedures

A review of the facility's policy and procedures for Medication Administration failed to address the storage, handling, dispensing, and administration of drugs and biologicals, including policy and procedures for the receipt, storage, and dispensing of scheduled medications.

Based on interview and record review, the facility failed to ensure a physician co-signed the history and physical for acute inpatient admissions for 10 (#s 1, 5, 6, 7, 9, 10, 11, 15, 18, and 19) of 20 sampled patients who were admitted to the hospital. This deficient practice had the potential to affect all patients admitted to the hospital. Findings include:

Review of the following patient medical charts showed there was no physician co-signature noted on the admission history and physical completed by the mid-level practitioners for:

- patient #1, admitted on 7/26/24,
- patient #5, admitted on 4/3/24,
- patient #6, admitted on 6/14/24,
- patient #7, admitted on 4/16/24,
- patient #9, admitted on 12/4/23,
- patient #10, admitted on 10/30/23,
- patient #11, admitted on 11/24/23,
- patient #15, admitted on 7/25/23,
- patient #18, admitted on 8/3/23, and
- patient #19, admitted on 3/5/24.

During an interview on 7/31/24 at 10:00 a.m., staff member A stated they were not aware a physician needed to co-sign all admitting mid-level practitioners' history and physicals for patients, assuming full responsibility of the patients care. Staff member A stated they only notified the provider when a mid-level practitioner admitted a patient to acute care services.

During an interview on 7/31/24 at 10:00 a.m., staff member H stated she had not been reviewing inpatient records of patients who were admitted by Nurse Practitioners or Physician Assistants. Staff member H stated, "I am supposed to, but I have not done it yet."

A document request for the facility's policy and procedure for a physician co-signature of the history and physical for acute inpatient admissions was requested on 7/31/24 at 10:00 a.m. No additional documentation was received by the end of the survey.



47752

Due to the manner and degree of the deficient practice, the facility failed to meet the Condition of Participation for Infection Prevention and Control.

Based on interview and record review the facility failed to:

-Ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. (See C1204).

- Ensure specific surveillance, tracking, and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. (See C 1208).

-Ensure the facility had a system in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. (See C1225).

-Ensure the facility integrated all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases through the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients receiving care at the facility. (See C1229).

-Ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. (See C1235).

-Ensure the individuals employed as the Infection Prevention and Control Specialists provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. (See C1250).

Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist was qualified through education, training, experience and/or certification in infection prevention and control practices. This deficient practice had the potential to affect all patients receiving care and staff providing care at the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated she was appointed as the Infection Preventionist about a year and a half ago. Staff member I stated she had no education or certification in Infection Prevention. Staff member I stated she had been learning as she went and had joined APIC (Association for Professionals in Infection Control and Epidemiology). Staff member I stated she had not done any other education in Infection Control.

Record review of the facilities personnel file for staff member I did not show documentation of education, training, certification, or experience in Infection Prevention.

Based on interview and record review, the facility failed to ensure specific surveillance, tracking, and trending of infections were established for the Infection Prevention and Control Program. This deficient practice had the potential to affect all patients receiving care within the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had no documentation of surveillance, tracking or trending of infections. Staff member I stated, "I tried tracking and trending, but it just didn't work for me."

Review of a facility document titled, "Infection Prevention and Control," undated, showed:
... "The infection Prevention and Control Committee is a multidisciplinary committee which oversees the program for prevention, surveillance, data analysis, and control of infection."

Based on interview and record review, the facility failed to ensure a system was in place for active surveillance, prevention, and control of all infections, to include antibiotic use. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated there was not any documentation showing surveillance, tracking or trending of infections or antibiotic use. Staff member I stated, "We have a urine thing (McGreer's Criteria) we are supposed to follow, but nobody follows it. The providers order what they want. I have gotten resistance and push back from the providers when I mention it to them."

Review of a facility document titled, "Antimicrobial Stewardship Program," dated, 4/28/22, showed:
... "5. Track-hospital monitors antibiotic use
6. Report-Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing
7. Educate-the stewardship program provide education to clinicians and other relevant staff on improving antibiotic use" [sic]

Based on interview and record review, the facility failed to integrate all Healthcare Associated Infections, Antibiotic Stewardship, and other infectious diseases through the facilities QAPI leadership and program. This deficient practice had the potential to affect all patients receiving care at the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated, "I am not addressing anything with QA or QAPI at this time."

Review of a facility document titled, "QA/QI Minutes," dated 6/15/23-2/22/24 and 5/15/24-7/17/24, showed no infection prevention and control attendance at the QA/QAPI meeting, or submission of information to the QA/QAPI leadership.

No policy or procedure was in place for the integration of the Infection Prevention and Control Program to QAPI leadership or program.

Based on interview and record review, the facility failed to ensure complete documentation of the infection prevention and control program, to include surveillance, and tracking of infections. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had no documentation of surveillance, tracking or trending of infections. Staff member I stated, "I tried tracking and trending, but it just did not work for me."

Review of a facility document titled, "Infection Prevention and Control," undated, showed:
... "The infection Prevention and Control Committee is a multidisciplinary committee which oversees the program for prevention, surveillance, data analysis, and control of infection.
... 1. A written plan should serve as the foundation of any surveillance program." ...

Based on interview and record review, the facility failed to ensure the individual employed as the Infection Prevention and Control Specialist provided competency-based training and education to all personnel and staff, including medical staff, on the practical applications of antibiotic stewardship guidelines, policies, and procedures. This deficient practice had the potential to affect all patients and staff within the facility. Findings include:

During an interview on 7/30/24 at 3:30 p.m., staff member I stated she had not done any education with any of the staff. Staff member I stated, " I have tried to educate providers on antibiotic stewardship, but providers order what they want. I have gotten resistance and push back from the providers when I mention it to them."

Review of a facility document titled, "Antimicrobial Stewardship Program," dated, 4/28/22, showed:
... "5. Track-hospital monitors antibiotic use
6. Report-Prescribers receive feedback by the stewardship program about how they can improve their antibiotic prescribing
7. Educate-the stewardship program provide education to clinicians and other relevant staff on improving antibiotic use" [sic]

Based on interview and record review, the facility failed to periodically review death records with the OPO (Organ Procurement Organization) for 2 (#s 5 and 9) of 2 sampled patients who expired in the facility; failed to develop policies and procedures for the purposes identified in their agreement with the tissue and eye banks information that will allow the OPO, tissue bank and eye bank to assess the CAH'S donor potential; failed to develop and implement policy and procedures which outline the agreement with an organ and eye bank; and failed to identify areas through involvement of the facility's OPO program with their QAPI (Quality Assurance and Performance Improvement) program to identify where the OPO, tissue bank and eye bank staff performance might be improved. Findings include:

1. Failure to Review Death Records with OPO

Review of patient #5's EMR, dated 4/3/24 to 4/18/24, showed the patient expired in the facility on 4/18/24. The EMR showed the OPO was notified of the death in the facility.

Review of patient #'s EMR, dated 12/4/23 to 12/6/23, showed the patient expired in the facility on 12/6/23. The EMR showed the OPO was notified of the death in the facility

During an interview on 7/30/24 at 3:00 p.m., staff member B stated she had not reviewed any death records or been in contact with the organ or eye banks to review the death records.

2. Failure to Develop Policy and Procedures for OPO Review

During an interview on 7/30/24 at 3:00 p.m., staff member B stated the facility did not have any policies and procedures for their OPO program, therefore none which permit the OPO, tissue bank and eye bank access to death record information that will allow the OPO, tissue bank and eye bank to assess the CAH'S donor potential.

A review of the facility's Organ Recovery Agreement, dated, 12/2/2013, showed:
"... 2.9 Work cooperatively with [Organ Bank] to determine Hospital's donor potential, review death records to improve identification of potential donors, develop strategies for improving donation rates, and identify areas with both [Organ Bank] and Hospital staff performance might be improved."

A review of the facility's Policy and Procedure titled, Organ Procurement, with no date, showed, "Please refer to the Organ Procurement Policy and Procedure book."

A review of the facility's OPO Policy and Procedure Book failed to address any policy and procedures for OPO.

3. Failure to Develop OPO Policy and Procedures

A review of the facility's Policy and Procedure titled, Organ Procurement, with no date, showed, "Please refer to the Organ Procurement Policy and Procedure book."

A review of the facility's OPO Policy and Procedure Book failed to address any policy and procedures for OPO.

4. Failure to Incorporate OPO into QAPI

During an interview on 7/30/24 at 3:00 p.m., staff member B stated the facility's OPO program was not integrated into the facility QAPI program.