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Based on observation, interview, and record review, the facility failed to ensure patients' dignity was protected for 2 (#s 1 and 9) of 9 patients sampled. Findings include:

1. During an observation 12/18/18 at 4:50 p.m., patient #1 was being assisted to her room via her wheelchair by staff members C and D. Patient #1 was a paraplegic and required assistance with toileting as she was incontinent. Staff members C and D stopped in the hallway in an open commons area where patients can sit and read a newspaper or play games. While staff members C and D were stopped with patient #1 in the common area, staff member C stated three times out loud, in front of other staff and patients, "This one needs changed." Patient #1 looked down at the floor and did not say anything at that time. Staff members C and D then continued to take patient #1 to her room.

During an interview on 12/19/18 at 10:50 a.m., patient #1 stated she did not like it when staff member C kept saying "This one needs to be changed." Patient #1 stated "It was degrading."

During an interview on 12/19/18 at 3:30 p.m. staff member D stated "We are supposed to keep patient's care needs confidential between the patient and the staff to protect their dignity." Staff member D stated staff member C should not have said that about patient #1 in the common area for everyone to hear.

2. During an observation and interview on 12/18/18 at 4:30 p.m., patient # 9 was eating his supper meal. He had chin hair and a mustache, and a growth of hair on his neck and sides of his face. The hair on his neck and sides of his face was not similar his moustache and chin hair. Patient #9 stated he liked to be shaved every day on his neck and sides of his face. He stated he needed a razor to shave. Patient #9 asked if he could have an appointment to get shaved for the Christmas dinner he was invited to the next day. Staff member D stated normally the men on the unit were shaved on their bath day. Staff member D was made aware patient #9 wanted to be shaved.

During an observation on 12/19/18 at 3:45 p.m., patient #9 was at the Christmas dinner in the main building rotunda. Patient #9's face was observed, and he had not been shaved as he had wanted, prior to attending the dinner.

Review of the facility policy titled Montana State Hospital Rights of Patients showed, "...#22 The right to have staff assist you as needed. #23 The right to assistance and special provisions if you have a physical disability..."

Based on observation, interview, and record review, the facility failed to ensure a patient received assistance to adjust a pillow, positioned under her feet, on her wheelchair pedals, placing her feet at risk for increased edema and skin breakdown for 1 (#1) of 9 sampled residents. Findings include:

Patient #1 was admitted to the facility with diagnoses including depression, diabetes Type II, and T6 paraplegia.

During an observation and interview on 12/18/18 at 3:35 p.m., patient #1 asked staff member C for help adjusting the pillow that her feet were resting on that was falling off her wheelchair pedals. Staff member C kept walking and stated, "I can't I have to be with someone else right now." Staff member C was observed to walk to the other end of the hall with another staff and patient who was ambulatory. Staff member C passed by several other staff in the hallway and did not ask them to assist patient #1 with adjusting the pillow that was falling off of the wheelchair pedals. Patient #1 was not able to safely adjust the pillow as she would have fallen out of her wheelchair if she leaned that far forward. Staff member C stated if she could not help a patient, she would ask another staff member to help. Staff member C had not asked another staff member until she was asked by the surveyor why she had not obtained help for patient #1. Staff member I heard the above conversation and assisted patient #1 with her foot pillow. Staff member I stated if they are assigned to a 1:1 with a patient they still need to let other staff know if someone needed help. Patient #1's feet were edematous, and the skin on both feet were tight and reddish purple in color especially to the left foot.

Review of the facility policy titled Montana State Hospital Rights of Patients showed, "...#22 The right to have staff assist you as needed. #23 The right to assistance and special provisions if you have a physical disability..."

Based on observation, interview, and record review, the facility failed to ensure a patient was provided services that were ordered by the provider regarding placement of a Foley catheter, and a physical therapy evaluation for range of motion exercises to her lower extremities resulting in the patient crying, feeling hopeless, and placing her at risk for stasis ulcers to her foot for 1 (#1); failed to follow treatment orders to toilet an incontinent patient every 2 hours placing the resident at risk for skin breakdown for 1 (# 1); failed to monitor the skin condition and lower extremities for a paraplegic patient placing her at risk for stasis ulcers to her left foot for 1 (#1); failed to provide baths and shave male patients for 2 (#s 2, and 9); and, failed to ensure a resident with a diabetic ulcer to his right foot had a proper fitting shoe, placing him at risk for interfering with the healing process of the ulcer for 1 (#3) of 9 sampled patients. Findings include:

1. Patient #1 was admitted to the facility with diagnoses including T 6 paraplegia, diabetes type 2, neurogenic bladder, and depression.

During an observation and interview on 12/18/18 at 10:54 a.m., staff members G and M assisted patient #1 with her ADLs, incontinent care, and a Hoyer lift transfer from her bed into her wheelchair. Patient #1 stated she had concerns about her care.

During an observation and interview on 12/18/18 at 2:40 p.m., patient #1 stated she was not getting range of motion to her lower extremities. She stated her legs were getting tight and drawing up. She stated at home, and while she was in another hospital setting prior to being here, she received range of motion therapy to her lower extremities. She stated the staff had not provided her range of motion since her admission here. She stated the staff did not move her feet or ask her if she wanted to elevate them. Patient #1's feet were edematous and reddish purple in color with scabbed areas noted to her left great and second toes, anterior and just below the nails. She stated, "my right foot feels like it's going to fall off." She stated she has had a urinary catheter since 2005 and that she has been waiting for staff to provide her with another urinary catheter and they had told her it would probably be in today. She stated in the past, she self-cathed but it was not working anymore, so she has had a catheter ever since. She stated she never had to wear a diaper and did not want to. She stated she did not want to be wet with urine nor woke up during the night to be changed if she was incontinent.

Review of patient #1's medical record showed a physician's order, dated 12/14/18 at 3:30 p.m., for a "28 french urinary catheter (chronic urinary incontinence T 6 paraplegia)." A physician occupational therapy order, dated 12/10/18 at 2:45 p.m., showed "physical therapy referral for ROM, toilet every 2 hours while awake and every 4 hours while asleep, staff assist with ADL's and hygiene." On the physician's order sheet was an order, dated 12/11/18, which showed "physical therapy evaluation for lower extremities." The Initial Nursing Assessment, dated 12/6/18 at 3:07 p.m., did not show patient #1 had any skin issues on her left foot.

Review of patient #1's Treatment Plan, with a begin date of 12/13/18, showed staff would assist her with positioning in her chair and her feet, ADLs, and her skin/wound care.

During an observation on 12/18/18 at 4:00 p.m., patient #1 was still in her wheelchair. She stated no one had offered to toilet her since she had gotten up earlier that morning at 10:54 a.m. She stated she was incontinent of urine. Her right leg was dangling and not on the pillow on her wheelchair pedal. Her right foot was red and purple in color with pitting edema, and the skin was shiny and tight on her foot and ankle.

During an observation on 12/18/18 at 4:50 p.m., patient #1 was in the hallway crying and asked the nurse if she could tell her why her catheter was not there yet. The nurse told her she did not know. Patient #1 was being assisted to her room via her wheelchair by staff members C and D. While staff member C and D were stopped with patient #1 in the common area, staff member C stated three times out loud, in front of other staff and patients, "This one needs changed." Patient #1 looked down at the floor and did not say anything at that time. Staff member C and D then continued to take patient #1 to her room. Patient #1 had been in her wheel chair from 10:54 a.m. until 4:50 p.m. without being toileted every two hours.

During an interview on 12/19/18 at 10:50 a.m., patient #1 stated she asked staff member E about her catheter this morning and staff member E told her she would check with the ward clerk. Patient #1 stated she had to wait until after 10:00 a.m. this morning for the nurse to do her treatment to her pressure ulcer. She stated she got up at approximately 10:35 a.m.

During an observation and interview on 12/19/18 at 11:25 a.m., staff member F was notified that patient #1's catheter that had been ordered on 12/14 had not arrived and patient #1 was distressed no one could tell her what the status was. Staff member F stated, "I will visit with her (patient #1) regarding her catheter not being here." Staff member F examined and interviewed patient #1. Staff member F stated, "Her feet need to be elevated. They weren't red last week but they were swollen. They need to be elevated. She should be on a diuretic. They were not discolored last week. I was not aware she was not being toileted every two hours, or that she did not have her catheter yet and that the physical therapy consult had not happened. I will make a priority for her for range of motion every day and to toilet her every two hours."

During an interview on 12/19/18 at 11:30 a.m., staff member J stated she had just started her position as the unit's ward clerk. She stated she was not sure if the catheter was ordered last week. She stated the staff member she replaced had retired last Friday and she was not sure if she had ordered the catheter.

During an interview on 12/19/18 at 11:35 a.m., staff member B stated the ward clerk would order the catheter and, when it arrived, she would give it to the nurse. She stated the process involves the purchasing department and the warehouse. She stated she had just spoken with the purchasing department and it was received.

During an interview on 12/19/18 at 12:00 p.m., regarding toileting patients every two hours, staff member F stated, "we have forty patients here and we have two RNs to do treatments and take off physician's orders. They (RNs) rely on the psych techs to do their job."

During an observation and interview on 12/19/18 at 1:10 p.m., staff member F assessed patient #1's feet. She stated patient #1 had a stasis ulcer to her left great toe and it should have had a follow-up and a specific treatment plan. Patient #1 stated no one had toileted her since she got up this morning at 10:30 a.m.

During an interview on 12/19/18 at 2:17 p.m., staff member A stated if the patient has an order for a consult, a Consult Sheet was completed in the computer. She stated after it is entered in the computer, they must notify the guardian, the provider, and the medical director. She stated the consult must be approved and then it would go to the billing department and then an appointment would be made. She stated currently, the consult was in the computer, but it stopped there. She stated the order should have been finished and then the appointment would have been made. Staff member A stated for patients that are needing to be toileted every two hours, staff had to mark on the flow sheets that it was completed for each patient. She stated staff are not good about documenting when they do this. She stated in the future they have discussed assigning staff to a hallway to better track completion.

2. During an observation on 12/18/18 at 2:10 p.m., patient #2 was observed sitting in the hallway in his wheelchair. He had a seat belt that was not fastened. He was observed to have a growth of facial hair. He stated he liked to shave his face every day. He stated he needs help to use the bathroom.

Review of patient #2's Treatment Plan, with a begin date of 10/1/18, showed staff were to toilet him every 2 hours, provide assistance with ADL's, and provide 1:1 monitoring for safety related to his fall risk.

During an observation of the supper meal time on 12/18/18 at 4:30 p.m., patients #s 2 and 9 had facial hair growth and their hair was not combed. Patient #9 was eating his supper meal. He had chin hair and a mustache, and a growth of hair on his neck and sides of his face. The hair on his neck and sides of his face was not fully grown out like his moustache and chin hair. Patient #9 stated he liked to be shaved every day on his neck and sides of his face. He stated he needed a razor to shave. Patient #9 asked if he could have an appointment to get shaved for the Christmas dinner he was invited to the next day. Staff member D stated normally the men on the unit were shaved on their bath day. Staff member D was made aware patient #9 wanted to be shaved.

During an observation on 12/19/18 at 9:50 a.m., patient #2 was in the hallway in his wheelchair. He had a growth of facial hair.

During an observation on 12/19/18 at 1:20 p.m., patient #2 continued to be in his wheel chair in the television room and he remained unshaved.

During an observation on 12/19/18 at 3:30 p.m., patient #2 was sitting in his wheelchair in the television room. His face continued to not be shaved.

During an observation on 12/19/18 at 3:45 p.m., patient #9 was at the Christmas dinner in the main building rotunda. Patient #9's face was observed, and he had not been shaved as he had wanted, prior to attending the dinner.

Review of the facility log titled Bath Checklist October 2018 showed patient #2 was given one bath between 10/1/18-10/17/18 on 10/10/18. Baths were recorded as given daily on 10/17/18-10/24/18. No baths were recorded for the dates of 10/25/18-10/31/18. The log showed patient #9 was given a bath on 10/15/18, 10/17/18, 10/20/18 and 10/23/18.

Review of the facility log titled Bath Checklist November 2018 showed patient #2 was given a total of five baths for the month of November on 11/4/18, 11/7/18, 11/14/18, 11/18/18, and 11/21/18. Patient #9 was given one bath in November 2018 on 11/6/18.

3. Patient #3 was admitted with the diagnoses of Diabetes Mellitus II, left below the knee amputation, and status post CVA.

Review of patient #3's treatment plan, with a begin date of 9/5/18, included staff were to assist him with ADL's, eating, toilet every 2 hours, and wound care with regular foot soaks.

During an observation on 12/18/18 at 10:00 a.m., staff member L assisted patient #3 with a dressing change to a diabetic ulcer on his right heel. Staff member L soaked patient #3's right foot, dried it, and applied sure prep to the area. Staff member L placed patient #3's sock on and his tan colored Crocs shoe. After attempting to put on the Crocs shoe, staff member L stated, "the shoe doesn't fit right, and his right heel hits the shoe right where the ulcer is." Staff member L stated, "that could be the cause of the sore" and stated he would report the ill-fitting shoe and see about getting a different shoe for him that fit.

During an observation on 12/19/18 at 9:58 a.m., patient #3 was in the hallway in his wheelchair and had on a different black shoe form the tan Crocs shoe he wore on 12/18/18. The black shoe was not on his foot properly and his left heel was resting on the back of the shoe where the diabetic ulcer was on his heel. Staff member N was notified of the ill-fitting black shoe and that it was a different shoe from the tan colored Crocs shoe on his foot on 12/18/18 that also did not fit.

During an interview on 12/20/18 at 1:44 p.m., staff member K stated he had worked on [name of the unit] for several months and stated, "this week there were people working that I hadn't met before. Yesterday, the afternoon staff was almost all new." Staff member K stated, "we have two nurses on our unit. We have a paper by the door at the nurse's station the floor nurse should be checking and doing rounds every two hours to make sure toileting and baths are being done." Staff member K stated, "some of the nurses won't say anything if stuff is not done. I told [name of nurse] in the past about people not getting their work done and she told me to go yell at them." Staff member K stated the nurses get pulled to other units. He stated the nurses are here three to four times per week from 7 a.m. to 7 p.m. He stated patients don't always get toileted every two hours because some staff "don't want to deal with it." He stated, "the last three days we have had more than enough people to do the job and no one is enforcing it."

Based on observation, interview, and record review, the facility failed to ensure staff were following effective hand hygiene with glove use and disposal of a used glucometer strip and lancet to mitigate risks associated with healthcare-associated infections during care observations for patient #1. Findings include:

1. During an observation and interview on 12/18/18 at 10:54 a.m., staff members G and M assisted patient #1 with her ADLs, incontinent care, and a Hoyer lift transfer from her bed into her wheelchair. Staff members G and M applied gloves. They did not wash their hands or sanitize prior to putting on their gloves. Patient #1 was incontinent of stool. Staff member G obtained cleaning wipes and cleansed patient #1's perineal area. After cleansing the stool from patient #1, staff member G log rolled her while touching her legs, and cleansed the front of the patient. Staff member G then touched patient #1's clean gown, placed her pillow at the head of her bed, moved her bangs back from her face, picked up patient #1's oxygen tubing and placed it on the oxygen concentrator, turned off the concentrator, opened the bathroom door, left patient #1's room and returned with her wheelchair cushion, and assisted staff member M to transfer patient #1 into her wheelchair, with the contaminated gloves on. Staff member G stated she should have taken her gloves off right after she performed the incontinent care. She stated they do not have sanitizer or gloves in the rooms, so staff had to carry gloves in their pocket. There was soap observed in patient #1's bathroom, and staff members G and M washed their hands prior to leaving patient #1's room.

2. During an observation on 12/18/18 at 11:22 a.m., staff member H checked patient #1's blood glucose level. Staff member H came into patient #1's room with a white plastic basket with a handle that contained supplies used to check the patient's blood glucose. The container had cotton balls, individual alcohol prep pads, a glucometer, test strip container, and a Band-Aid. Staff member H applied gloves and removed a test strip from the container and applied to the glucometer. Staff member H opened an alcohol swab and cleansed patient #1's right 3rd digit. Staff member H obtained a lancet from the basket and used it on patient #1's cleansed finger. Staff member H placed the test strip on the finger after wiping it, and collected blood onto the test strip. Staff member H placed the used lancet, the test strip and the used alcohol wipe packet into the clean supply basket in one of the corners of the basket. Staff member H then removed her gloves rolling them off of the hands inside out and placed them in her back pocket of her pants. Staff member H stated she did not want to throw the lancet and strip away in patient #1's garbage, so she put it in the basket and would place it in the medication room garbage and sharps container then. Staff member H left patient #1's room and did not wash or sanitize her hands prior to leaving the room.

Review of the facility policy and procedure titled Glove Use showed, "...3. Remove gloves after caring for a patient. Remove gloves prior to leaving the patient's living area... 5. Hand washing or hand rubbing with alcohol based hand rubs should be performed before, and after donning, and removing gloves... 8. Gloves are not to be stored in pockets for later use."

Review of the facility policy and procedure titled Handwashing showed, "...II. Policy: Hospital personnel shall wash their hands to prevent the spread of infections: ...4. After removing gloves... 7. If moving from a contaminated body site to a clean body site during patient care... IV. Responsibilities: A. The hospital will provide hand washing facilities. Where sinks are not practical, alcohol based hand rub shall be available..."

Review of the facility policy and procedure titled Handling of Needles, Sharps & Razors showed, "...II. Policy: Personnel will use the biohazard marked disposable needle collection containers whenever disposing of syringes, lancets, needles or any other collection device that is used to puncture a patient's skin, or disposable razors and sharps... V. Procedures: ...2. Discard sharp objects intact immediately after use into the biohazard marked impervious needle disposal container conveniently placed in all clinical areas, or in the smaller portable container for remote use..."

Review of the facility nursing procedure titled Blood Glucose Level Testing showed, "...Procedure: ...2. n. Remove the test strip and dispose of it according to hospital policy... q. remove gloves and perform hand hygiene..."