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Based on observation and staff interview, the facility failed to properly post notification signs regarding the absence of a Medical Doctor (MD) or Doctor of Osteopathy (DO) in 1 of 1 emergency rooms. Findings include:

On 4/7/14, beginning at 10:10 a.m., the surveyor observed the facility entrances and the emergency department. There were no signs posted inside or outside of the emergency room or in other prominent locations within the facility.?

On 4/7/14 at 11:10 a.m., an interview was conducted with staff member B, the staff nurse on duty for the emergency room. Staff member B verified that there were no signs posted to notify patients that an MD or DO was not available in the facility 24 hours a day, seven days a week.


? Federal Regulations read as follows;
Individual notices are not required in the CAH's dedicated emergency department (DED) (as that term is defined in 42 CFR 489.24(b), but the DED must post a notice conspicuously, in a place or places likely to be noticed by all individuals entering the dedicated emergency department. The posted notice must state that the CAH does not have a doctor of medicine or a doctor of osteopathy present in the hospital 24 hours per day, 7 days per week, and must indicate how the CAH will meet the medical needs of any patient with an emergency medical condition, as defined in 42 CFR 489.24(b).

Based on observation and staff interview, facility staff failed to ensure that emergency supplies related to infants and adults were readily available for use in the hospital emergency department. Findings include:

On 4/7/14 at 10:10 a.m., the surveyor reviewed the emergency department. During the review of the pediatric emergency cart, the surveyor observed multiple expired patient care supplies available for use for patients presenting to the emergency department for care:
- one 4.5 french uncuffed endotracheal tube with the manufacturer's expiration date of 9/13.
- one 5.5 french uncuffed endotracheal tube with the manufacturer's expiration date of 9/13.
- one 6.0 french cuffed endotracheal tube with the manufacturer's expiration date of 9/13.
- one 6.5 french cuffed endotracheal tube with the manufacturer's expiration date of 9/13.
- two Pedi-Cap end tidal CO2 detectors with the manufacturer's expiration date of 12/13.
The endotracheal tubes were individually marked with the notation that replacement tubes had been ordered on 7/29/13.

The cart also contained the following items;
- one Ambu brand size #1 Infant LMA with the manufacturer's expiration date of 5/13.
- one Ambu brand size #1 1/2 Infant LMA with the manufacturer's expiration date of 4/13.
- one Ambu brand size #3 Adult LMA with the manufacturer's expiration date of 11/13.
- one Ambu brand size #4 Adult LMA with the manufacturer's expiration date of 11/13.

Review of the other emergency supplies available in the emergency department revealed that there were no additional infant intubation supplies available for use in the department.

The surveyor interviewed staff member B, the staff nurse on duty for the emergency room, on 4/7/14 at 11:10 a.m. Staff member B verified the expiration dates of the intubation supplies. The nurse stated that the nurses check supplies for expiration dates monthly but he was not sure when the pediatric cart had last been checked. Staff member B stated that the person who had done the monthly expiration date checks had left approximately one year before and current staff were not completing the checks.

Based on observations and staff interviews, the facility failed to ensure that the physical plant:

1. Was maintained to ensure the safety of patients (see C221);

2. All mechanical, electrical and patient care supplies and equipment were maintained in safe operating condition (see C222);

3. Assure the safety of patients in non-medical emergencies (see C227);

4. Meet the requirements for Life Safety From Fire (see C231).


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The potential cumulative effect of these systemic problems is that the critical access hospital may be unable to ensure the provision of safe and quality health care.

Based on observations and staff interviews, the facility failed to minimize patient exposure to hazards in the emergency room, medical floor, and areas of the hospital. Findings include:

1. On 4/7/14 at 10:10 a.m., the surveyor observed the emergency department. The surveyor noted that there was a single "E" size oxygen cylinder in the closet that was resting on its base. The cylinder was not in a carrier or chained to the wall to prevent it from falling.

The surveyor interviewed staff member B, emergency room nurse, on 4/7/14 at 10:45 a.m. Staff member B was unaware that there was an unsecured oxygen cylinder in the department.



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2. During an environmental tour beginning at 9:50 a.m. on 4/7/14, the surveyor observed on the bottom shelf of an unlocked cabinet in the bathing room, the following:

-Hydrox Isopropyl rubbing alcohol 70%;
-Cen-Kleen IV one step disinfectant; and
-Swisher Turquoise 3 disinfectant with quatenary ammonia.

"Keep out of reach of children" was written on each of the product labels. The chemicals were also unlocked on 4/9/14 at 10:31 a.m.

3. On 4/7/14 at 10:15 a.m., the surveyor toured the activity room kitchen. When the surveyor turned on the stove burner knobs, the stove light lit up. Staff member L, the activity director, said "That's not supposed to be on." Staff member L reached into an unlocked cupboard and threw the breaker off. Staff member L said that staff sometimes use the activity room kitchen to heat their lunch.

Based on observations and staff interviews, the facility failed to maintain care supplies to an acceptable level of quality in three (emergency department, laboratory, and medical floor) patient care areas of the facility. Findings include:

1. On 4/7/14 at 10:10 a.m., the surveyor reviewed the emergency department and noted multiple expired patient care supplies available for use for patients presenting to the emergency department for care:
- two Comfort Sampler ABG kits with the manufacturer's expiration date of 12/13.
- three Insyte Autoguard IV catheters with the manufacturer's expiration date of 8/13.
- five Microtainer infant blood collection tubes with the manufacturer's expiration date of 1/10.

On 4/7/14 at 11:10 a.m., staff member B, the staff nurse on duty for the emergency room, verified the expiration dates of the identified supplies. The nurse also stated that nursing did monthly checks for expiration dates of the supplies. Staff member B stated that the person who had done the monthly expiration date checks had left approximately one year before and current staff were not completing the checks.

2. On 4/7/14, at 3:20 p.m. the surveyor reviewed the facility laboratory and noted multiple expired patient care supplies available for use for patients presenting to the emergency department for care:
- twelve green top pediatric blood collection tubes with the manufacturer's expiration date of 10/13.
- 350 purple top pediatric blood collection tubes with the manufacturer's expiration dates of,
3/12 (150), 9/12 (100), and 5/11 (100).

Staff member F, the laboratory manager, accompanied the surveyor during the department review and verified the expiration dates of the supplies at the time of identification. She stated staff checked the expiration dates of supplies at least monthly.

3. On 4/8/14, at 7:45 a.m., the surveyor reviewed the medical floor and medication room. The following multiple expired patient care supplies available for use for patients presenting to the emergency department for care:
- two 23 ga. by 3/4 inch Butterfly IV catheters with the manufacturer's expiration date of 12/13.
- two 20 ga. by .75 inch Insyte Autoguard IV catheters with the manufacturer's expiration date of 8/13.
- one 14 ga. by 1.75 inch Insyte Autoguard IV catheters with the manufacturer's expiration date of 8/13.
- eleven 1 gm. sterile foil packets of Povidone-Iodine ointment with the manufacturer's expiration date of 3/12.
- seven 0.9 gm. sterile foil packets of Double Antibiotic ointment with the manufacturer's expiration date of 5/13.
- four 4 ml. Vacuette blood collection tubes with the manufacturer's expiration dates of 4/13 (1), 11/13 (1), 12/13 (1), and 1/14 (1).

The expiration dates of the supplies was verified by staff member D, the staff nurse on duty for the swing bed patients at the time of the observations.



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4. The surveyor observed the microwave at the coffee bar in the dining room on 4/7/14 at 9:25 a.m. and on 4/9/13 at 10:31 a.m. The microwave had dried food on the inside roof of the microwave. On 4/7/14 at 10:15 a.m., the surveyor toured the activity room kitchen. There was dried food substance on the turning plate of the microwave. Staff member L, the activity director, said staff sometimes heats their lunch in the activity room kitchen.

Based on record review and interview with maintenance staff, the facility failed to assure that fire drills were held at least quarterly on all shifts.

The findings include:

In accordance with NFPA 101 Life Safety Code, 2000 Edition, and Section 19.7.1.2, fire drills in health care occupancies shall include the transmission of a fire alarm signal and simulation of emergency fire conditions. Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 p.m. (2100 hours) and 6:00 a.m. (0600 hours), a coded announcement shall be permitted to be used instead of audible alarms.
Exception: Infirm or bedridden patients shall not be required to be moved during drills to safe areas or to the exterior of the building.

Annex A.19.7.1.2 also adds the following clarification: many health care occupancies conduct fire drills without disturbing patients by choosing the location of the simulated emergency in advance and by closing the doors to patients ' rooms or wards in the vicinity prior to initiation of the drill. The purpose of a fire drill is to test and evaluate the efficiency, knowledge, and response of institutional personnel in implementing the facility fire emergency plan. Its purpose is not to disturb or excite patients. Fire drills should be scheduled on a random basis to ensure that personnel in health care facilities are drilled not less than once in each 3-month period.
Drills should consider the ability to move patients to an adjacent smoke compartment. Relocation can be practiced using simulated patients or empty wheelchairs.

The fire drills were reviewed on 4/9/14 at 11:00 a.m. The first quarter of 2013 was missing the day and night shift fire drills, the second quarter was missing the day and night shift fire drills, the third quarter was missing the day and night shift fire drills. The first quarter of 2014 was missing the day and night fire drills. There were only 2 out of 10 completed fire drills in the last five quarters.

An interview of maintenance staff indicated no other fire drills were conducted for 2013-14.

This deficiency has the potential to affect all patients/residents, visitors and staff in five of five smoke compartments.

Based on record review, interviews, and observations; the facility failed to meet the Life Safety Code requirements.

Findings include:

The facility failed to comply with the 2000 Edition of the National Fire Protection Association 101 Life Safety Code. Please see the life safety code statement of deficiencies for further information.

These deficiencies have potential to affect all patients/residents, staff, and visitors in all five smoke compartments.

Based on observation and staff interview, the facility failed to date and label all opened items stored in 1 of 1 refrigerators observed. Findings include:

On 4/7/14 at 9:32 a.m., the surveyor toured the kitchen with the dietary manager, staff member H. While reviewing items stored in the refrigerator, the surveyor noted a bowl of nuts and a bowl of cherries that had a plastic covering but were not labeled and dated. The dietary manager said that the items were leftover from the ice cream social held the day before.

Based on record review, observation, and staff interviews, the facility failed to ensure that medications were administered according to physician's orders? to 1 (#21) of 30 sampled patients. Findings include:

During the observation of the medication administration pass on 4/9/14 starting at 7:45 a.m., the surveyor noted that the nurse did not give an ordered Calcium with Vitamin D liquid supplement to patient #21. The nurse, staff member D, stated that the medication was a family supplied medication, and the facility was awaiting a new bottle of the liquid. She stated that she was unsure if the attending physician had been notified that patient. #21 was not receiving the medication as ordered.

The surveyor looked back on the current and previous MAR and noted that the medication was last documented as given on March 30, 2014. After reviewing the nursing progress notes, physician progress notes, and orders, the surveyor was unable to locate documentation that the attending physician had been notified of the medication not being available for administration.

The facility policy for medication administration, with an adoption date of 2006, lacked specific instruction to staff to notify the attending physician if a medication was not available.

The surveyor interviewed staff member C, the registered nurse on duty, on 4/9/14 at 11:20 a.m. Staff member C stated that the family had failed to provide a refill of the liquid calcium preparation on several occasions. She stated that staff had probably become "complacent" about the medication and had not called the physician. She stated that the normal process would be to notify the pharmacist to obtain the medication, and then the attending physician.

Staff member K, the consulting pharmacist, was interviewed on 4/9/14 at 10:25 a.m. She stated that very few medications were brought from home for patients. She stated that she would notify the physician if a drug was not available.


? Clinical Nursing Skills, Sixth Edition. Smith, Duell, & Martin
Prentice Hall Publications, 2004.
Chapter 18, "Medication Administration", Pg. 519

"In the event of a medication error, the physician must be notified immediately so that the potential danger to the client is minimized."

Based on record review and staff interview, the facility staff failed to ensure the proper completion of consent forms for 4 (#s 3, 5, 6, and 7) of 16 reviewed emergency room patients. Findings include:

1. Patient #3 was admitted to the emergency department on 5/5/13 following a fall at home. The facility form labeled "Conditions of Admission" included the signature of the responsible party and date that the form was signed. The time of the signature was not documented and there was no witness identified to the signature.

2. Patient #5 was admitted to the emergency department on 5/20/13 with complaints of nausea and vomiting. The facility form labeled "Conditions of Admission" was not dated, the time was not documented, and did not contain the signature of the patient or responsible party. The form included a date, time, and signature of a witness.

3. Patient #6 was admitted to the emergency department on 6/5/13 following a syncopal episode. The facility form labeled "Conditions of Admission" was signed by the patient and the date and witness signature were present on the form. The time that the signature of the patient was obtained was not documented.

4. Patient #7 was admitted to the emergency department on 7/5/13 with oral lesions and fever. The patient was transferred to another facility with a higher capability to provide care. The facility form labeled "Interfacility Transfer Authorization" neither contained the documentation that the responsible party consented to the transfer, nor did it include the date, time, and signature of the responsible party.

An interview was conducted with staff member A, the executive assistant, on 4/8/14 at 4:30 p.m. Staff member A was unaware that consents were not being completed properly.

Based on document review and staff interviews, the facility failed to ensure that the quality assurance program evaluated the services provided by all departments of the hospital. Meeting minutes were missing for 2 of 4 quarterly meetings. Findings include:

1. During the review of the radiology department on 4/8/14 at 3:45 p.m., the surveyor asked staff member E, the department manager, about quality assurance projects. Staff member E stated they had finished a project on annual shielding inspections and in-patient review of films but did not have a current project for the department.


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2. During the review of the therapy department on 4/8/14 at about 2:00 p.m., staff member N, the therapy manager, stated he currently was not involved in a quality assurance project and had not completed one for some time.

3. The surveyor reviewed the facility Quality Improvement Plan. Under Scope and Integration, the surveyor noted the following: "The scope of the QA plan is enterprise wide. All personnel and departments are expected to be involved and engaged in the program. Involvement includes participation on QI teams, collecting data, data analysis, peer review, and participation in state and national QI initiatives."

4. The surveyor reviewed quarterly quality assurance committee minutes. The most recent meeting minutes were dated July 2013.

Based on document review and staff interview, the facility failed to ensure that 42 of 42 services provided by agreement or arrangement were reviewed for quality and met the requirements for all Conditions of Participation on an annual basis. Findings include:

On 4/7/14 at 8:45 a.m., the survey team provided a request for information to staff member A, the executive assistant, for the start of the survey. That request included the current list of services provided by contract or arrangement. Staff member A provided the list at 10:00 a.m. on 4/7/14. The columns identified on the list included the name of the contractor, description, date of contract, term of the contract duration, renewal date, annual fee, and a column for the documentation of the date when the contract was reviewed.

The column for the review was blank for all 42 contracts.

Review of the documentation of the annual program evaluation failed to reveal any documentation or mention of the review of contracted services.

The surveyor interviewed staff member A on 4/8/14 at 3:50 p.m. Staff member A stated that the facility CEO was responsible for the review of all contracted services. She stated that staff member M, the CEO, looked at contracts as needed, or when they came up for renewal. She stated that she was not aware of an annual review of the contracts performed by the CEO.

On 4/9/14 at 11:05 a.m., staff member M stated that he did not look at every contract every year.

Based on observation, record review and staff and resident interview, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being of each patient for 2 (#27 and #29) of 30 sampled patients. Findings include:

1. Resident #27 was admitted to the facility on 10/9/12; diagnoses included diabetes and hypertension. On 4/7/14 at 10:37 a.m., the surveyor interviewed resident #27 about the activity program. Resident #27 said "No, there's not enough to do here. We play bingo three times a week. There's a group of guys that like to play cards and we play Yahtzee, but I don't have the patience for that." When asked if there were any craft activities, resident #27 said that the activity director told her she had tried crafts once, but she had to finish all the crafts herself. Resident #27 said that there is nothing offered on the weekends. "There's no purpose to getting up in the morning as the days are very long."

2. Resident #29 was admitted to the facility on 7/12/13; diagnoses included hypertension, congestive heart failure and macular degeneration. On 4/8/13 at 8:35 a.m., the surveyor interviewed resident #29 about the activity program. She said "There's not lots to do. The main thing is cards, but I can't see the cards." She added "The gal comes up with little parties once in a while."

The surveyor reviewed the activity calendar. Games, including bingo, were scheduled at 2:00 p.m. Monday through Friday. A snack or social hour was scheduled at 3 p.m. Monday through Friday and a Bible Study scheduled Tuesdays at 4:00 p.m. The monthly birthday party was scheduled the second Friday of each month. There were no activities scheduled on Saturdays in February or March 2014. An Easter Egg Hunt was scheduled for Saturday, April 19. On Sundays, from Jan. 1, 2014 through the time of the survey, there was an "Ice Cream Social" scheduled at 3:00 p.m.

3. On 4/8/14 at 2:55 p.m., the surveyor interviewed the activity director, staff member L. When asked what the ice cream social involved, staff member L, explained that dietary provides some type of ice cream treat that the CNAs distribute to the residents in their rooms or in the dining room or television lounge area.

4. On 4/9/14, at 2:10 p.m., the surveyor observed three residents in the activity room playing cards with the activity director. Another resident watched the card game. At 4:00 p.m., the surveyor observed seven residents singing with two volunteers at Bible Study.

On 4/9/14 at 11:00 a.m., the surveyor interviewed resident #27. Staff member L had provided the surveyor with resident #27's individual activity attendance record. For 4/8/14, the activity record had check marks indicating that resident #27 had attended the following activities: One to one; visitors; current events, games, Montana reading, movies, pet therapy, reading, social hour, t.v., reminising (sic), and chit chat.

The surveyor reviewed this attendance record with resident #27. Resident #27 said that she had visitors and one-to-one conversations the day before. Regarding current events, she said she had read the newspaper. For "games," resident #27 said she had attended bingo. She said that she was unaware what "Montana Reading" was and had not watched a movie. For "pet therapy," she said she had seen the facility dog and for "reading," she had read during the day. She said she did not attend a "social hour," but had watched t.v. When asked if she had participated in "reminiscing," she said "probably" at some point during the day. For "chit chat," she said she had visited with staff and residents throughout the day.

In summary, the facility failed to provide an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental and psychosocial well-being of the residents.