HospitalInspections.org

Based on observation, interview, and document review, the facility failed to provide emergency services to meet the needs of patients as evidenced by:

1. Failure to ensure qualified staff with appropriate specialized training and experience in emergency care were available to respond to emergency needs of patients; and

2. Failure to provide qualified medical leadership to be responsible for the patient care provided in the Emergency Department including ensuring sufficient numbers of medical and nursing personnel were available to meet and respond to the emergency needs of patients.

The cumulative effect of these staffing practices resulted in the failure by the Critical Access Hospital (CAH) to meet statutorily mandated compliance with the Condition of Participation (CoP) for Emergency Services, 42 CFR § 485.618. Findings include:

The ED was a Level III Emergency Medical Service Department with seven beds and services available 24 hours per day providing care for approximately 15,000 visits annually. The CAH served as an EMS (Emergency Medical Service) base station. Paramedics and Emergency Medical Technicians would call into the ED when they had responded to a 911 emergency call in the community. A RN would have to be available to take the call to provide assistance, consult with physician(s), provide treatment/medications ordered by physician(s), and accept patient in route to the facility. The patient in route by ambulance to the hospital would be placed in a bed upon arrival and assessed/triaged for critical needs immediately.

1. On 8/4/2014 beginning at 3:30 PM the initial tour of the Emergency Department (ED) was conducted with the ED Nursing Manager. One RN was on duty, with the ED manager functioning as the second RN.

a. A review of the schedule for the week of the survey identified the core staffing pattern was for 1 RN for the day shift and 1 RN for the night shift. When asked who would be the second RN on these shifts, the manager stated due to the low census in the Medical Surgical unit, a nurse would float from the Medical Surgical unit each shift to the ED when needed.

b. On 8/5/2014 at 2:05 PM, four (4) patients were present in the ED, seeking emergency care. A supervisor from another unit was the 2nd RN. Two other nurses (dressed in surgical scrubs) were also assisting with patient care.

c. The ED nurse was in room 1 assessing the patient and at the same time delegating tasks to the RNs available in the ED. An IV (intravenous) line had to be started on 2 other patients and repeat vital signs were needed on a patient who had presented with low blood pressure.

d. At 2:16 p.m. EMS was on the phone line with another patient in route to the ED with approximate arrival in 2 to 3 minutes. At 2:22 PM, the patient arrived with acute symptoms from congestive heart failure and high blood pressure. EMS staff gave their report to the ED nurse, vital signs were completed by the nurse in scrubs and a very brief assessment was conducted by the ED nurse.

e. At the same time, the patient in bed 2 was awaiting transfer to a higher level of care to rule out myocardial infarction (heart attack). The patient was attached to a bedside cardiac monitor. The ED had no central station at the nurses' desk to alert the staff when the patient was having irregular, fast or slow cardiac rhythms. This patient was not being observed for life threatening heart rhythms during this time.

f. The second nurse in scrubs was preparing the patient in bed 1 for discharge, removing the IV line while the physician requested medical clearance forms.

g. At 2:40 PM, the ED nurse was triaging another patient from the waiting room who presented with low blood pressure, a history of blood pressure problems, and had been seen in the ED 5 days prior with the same symptoms. The patient was moved to room 7 after he/she was triaged.

h. The ED physician was writing orders for IVs, fluid resuscitation, antibiotics, and laboratory values such as blood cultures and pregnancy tests to assist in determination of diagnoses for some of the patients but was met with delays in reporting results. These delays further slowed discharges for patients who were determined to be stable.

i. The patient in room 1 was discharged at 2:50 PM. The room was cleaned immediately and another patient was moved to this ED room.

j. The patient who required a higher level of care in bed 2 was transferred by paramedic ambulance at 3:35 PM. Once the patient was transferred, the ED nurse took a break, leaving the manager from another department and the 2 nurses in scrubs in charge of the ED.

k. The nurses in scrubs were interviewed at 3:05 PM to confirm their roles in the ED. They stated, "We do what we can; start IVs, prepare patients for discharge and clean the rooms after discharge, just whatever we can."

2. Following the ED observations, a collaborative interview was conducted with the CEO (Chief Executive Officer), Acting Director of Nursing, and Clinical Director (MD). The ED observations were reviewed in detail. The staffing for the week was also reviewed in detail indicating 1 RN and 1 Physician (temporary) scheduled for the next day. The CEO stated that since he started in his new role of CEO in June 2014, "It has been a priority to increase the number of RNs from one to two per shift." It was confirmed by the acting DON that medical surgical nurses are assigned to float to ED.

3. During an interview on 8/5/2014 at 10:30 AM, the ED manager again confirmed the staffing of 1 RN per shift. She stated during peak times when the ED census increases, RNs are floated from the Medical Surgical unit or the Perioperative area. This practice had been routine since April of 2014 when the core staffing was decreased to one RN per shift. A core staffing or minimum staffing of two RNs was requested to no avail until June of 2014.

4. On 08/06/2014 at approximately 8:30 AM, Licensed Nurse (LN #11), who worked on the second shift (7 PM to 7 AM) in the in-patient unit was asked about how nurses were scheduled in connection with inpatient census. LN #11 indicated that two (2) LNs were on during the day shift along with a clerk; at night, there were two (2) LNs along with a Certified Nursing Assistant (CNA). LN #11 further explained that if there were no inpatients or only one patient, then one of the LNs would float to the ED. The CNA would also float to the ED if there were no inpatients.

5. A review of Medical Surgical nurse employee files was conducted with the management staff beginning on 8/6/2014 at 10 AM 100% or nine RN files were reviewed. Seven (7) of nine (9) RN employee files had no evidence of orientation, specialized training, cross training, recent experience, or current competencies in the care of the ED patient. These findings were validated by management staff.

6. Review of the facility's "Plan for Provision of Care" for the ED dated 2/11/2014 indicated under 'Description of Services' the following: "All patients.....shall receive a medical screening by an Emergency Department provider ....Qualified physician, registered nurses, and an interdisciplinary team provide assessment and treatment."

7. Review of the job description for the Clinical Nurse in the ED identified "Knowledge Required by the Position" included "Advanced knowledge of emergency room nursing theories, principles, practices, concepts and procedures as applied to the care of critically ill and severely injured patients i.e., prompt and decisive nursing assessment and diagnosis, problem-oriented care plan development; use of emergency drugs, interpretation of EKG (heart) strips, ABG's (arterial blood gases), laboratory data, etc." The key functions/duties included "performs specialized, professional nursing duties in the case of critically ill, severely injured and/or traumatized emergency patients. Assesses all patients presenting for emergency care and triages based on history, physical assessments and chief complaint; initiates treatments, medications, emergency and resuscitative measures based on appropriate utilization of standing orders, ACLS (Advanced Cardiac Life Support) and advanced ATLS (Advanced Trauma Life Support) protocols." It further stated the ED clinical nurse will "continually monitor and assess patients' clinical conditions and recognizes, identifies and interprets serious situations and immediately decides and initiates proper intervention independently. Notifies the physician when appropriate."

8. Review of the ENA (Emergency Nurses Association) position statement for 'Staffing and Productivity in the Emergency Department' dated 2010, indicated the following:
"It is the position of the Emergency Nurses Association that ....there should be a minimum of two registered nurses whose responsibility is to provide care in the emergency department at all times ....Evaluation of staffing should include the impact on registered nurse safety, patient and staff satisfaction, and the recruitment and retention of qualified registered nurses." (ENA.com)

9. Review of the ED record for Patient 2 revealed EMS had arrived with this patient at 11:38 AM on 8/5/2014. The patient had complaints of chest pain and alcohol withdrawal. The patient was triaged at 11:38 AM by a Perioperative nurse. Review of the employee file for this Perioperative nurse on 8/7/2014 identified the job description as an "Operating Room Nurse." The job description under major duties included under number 9 addendum the following: "Float to other departments as the need arises to be utilized within their scope of nursing practice with orientation to the particular unit." There was no evidence in the employee file to validate the RN was competent to perform the role as triage nurse in the ED. There was no evidence in the employee file of ED orientation, cross training, recent experience, triage nurse training or training on Emergency Medical Treatment and Labor Act (EMTALA).

10. The ENA position statement for 'Triage Qualifications' clearly states "general nursing education does not adequately prepare the emergency nurse for the complexities of the triage nurse role. Emergency nurses should complete a standardized triage education course that includes a didactic component and a clinical orientation with a preceptor prior to being assigned triage duties." In addition to the triage education, the nurse should acquire additional education to enhance triage knowledge, skills and abilities "such as ALS (Advanced Life Support) for the adult, pediatric and infant populations served." (ENA.com)

11. Review of the facility's 'Plan for Provision of Care' dated 2/11/2014 for the ED indicated under section 3 - Admission, Referral, or Extension Criteria; "All persons who present to the department will be triaged using the ESI system (Emergency Severity Index) by an appropriately trained registered nurse and medically screened by a qualified practitioner ..." The qualified RN will determine by the ESI system after initial evaluation and interventions, the acuity level of the patient as follows: "Level 1 -Resuscitation, Level 2 - Emergent, Level 3 - Urgent, Level 4 - Non Urgent, and Level 5 - Referred."

12. Review of the ED 'Clinical Guidelines' policy dated 3/2014 indicated qualified nursing staff may perform interventions, during the triage evaluation and prior to the evaluation by a medical provider in order to "expedite patient care." The interventions included interventions for chest pain, respiratory distress, trauma, bleeding, and hyperglycemia (high blood sugar).

13. During an interview on 8/8/2014 beginning at 3:35 PM, the ED manager confirmed the Perioperative nurses were not qualified to perform the duties of a triage nurse in the ED.

14. On 8/7/2014 at approximately 12:30 PM, the CEO announced an Emergency Department physician (E10) had accepted the position of ED Medical Director. The physician was in attendance and confirmed that she was happy to accept the position.

15. On 8/8/2014 a memorandum was submitted by the Clinical Director dated 7/2/2014 indicating "Effective 2 July 2014, the Emergency Room Medical Director responsibilities will be under the purview of Dr (E11). These duties will include the following: Direct Patient Care." The memorandum listed all of the direct care responsibilities similar to any physician working in an ED. The memo also stated, "All Administrative functions to include leave approval, Locum Tenems (temporary) schedules and contracting issues will continue to be under the purview of the Clinical Director of the Crow Service Unit. These duties are to be performed in conjunction with all other assigned duties and will remain in effect until rescinded by the Chief Executive Officer of the Crow Service Unit." The Clinical Director stated the MD assigned was in an acting role since July 2014. Based on the memo of assigned duties, the role did not include oversight and responsibility of the quality of care provided in the Emergency Department by all staff. Upon further review, the memo did not include the responsibility to ensure the appropriate types and number of qualified staff at all levels was available at all times to meet the needs of patients presenting to the ED for treatment.

16. The physician named in the 7/2/2014 memo as ED Medical Director was not on site during the week of the survey for interview. The role of the individual named by the CEO on 8/7/2014 as the ED Medical Director was not clear.



29642

Based on observations and staff interviews the Hospital failed to ensure that the premises were clean and orderly. Findings included:

During a tour of the facility, observations were made with the Facilities Director (Maintenance/Environment) on 8/7/2014. The Facilities Director (FD) confirmed the following areas were not maintained in a clean and orderly manner:

1. The ambulance bay area showed cigarette butts, dirt and leaves scattered over the floor. Although signage indicated the ambulance bay was a "No Smoking Area" the cigarette butts were noted in an area close to the storage of Oxygen E-tanks.

2. A janitorial closet near the radiology department was unlocked. This closet contained various chemicals which required secure storage.

3. The boiler room was observed during the tour and the FD indicated the hot water left the boiler area at approximately 130-135 degrees and returned at approximately 120 degrees. He indicated he did not monitor temperatures in patient care areas or public/staff areas to ensure hot water was not at a critical level.

4. The boiler room was observed with wet trash and soda cans littering the floor.

5. The laundry area was observed and the FD indicated most items for the patients were sent outside the CAH for laundry service. He indicated some items were laundered in the CAH. Empty soda cans in large open plastic bags were observed in the clean area of the laundry.

Based on observations (C0200), record review and staff interviews (C0200 and C0270) it was determined that the Governing Board and the Medical Staff failed to ensure the Critical Access Hospital (CAH) remained in compliance with statutorily mandated Conditions of Participation (CoPs). Findings included:

Review of Governing Body Meeting Minutes and Medical Staff Meeting Minutes from January 2014 through the 8/8/2014, Federal CMS survey showed these two bodies were responsible for the functionality of the hospital and adequacy of staff and medical services.

1. The Governing Body and Medical Staff failed to ensure the CAH provided an adequate system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. (See CoP for Provision of Services at 42 CFR § 485.635 (C0270)). Although both boards (per interview and review of meeting minutes) were aware of the admission of an active TB (Tuberculosis) patient to the CAH's inpatient unit, no actions were identified or implemented to ensure safely of staff working in the CAH. This failure resulted in an Immediate Jeopardy situation (see C0270 for details).

2. Additionally these responsible governing bodies failed to ensure compliance with the CoP for Emergency Services at 42 CFR § 485.618 (C0200), involving:

a. The failure to ensure qualified staff with appropriate specialized training and experience in emergency care were available to respond to emergency needs of patients; and

b. The failure to provide qualified medical leadership to be responsible for the patient care provided in the Emergency Department including ensuring sufficient numbers of medical and nursing personnel were available to meet and respond to the emergency needs of patients.

c. Review of meeting minutes showed these boards were aware of staffing patterns and shortages but no definitive actions were taken to improve staffing on a consistent and sustainable level.

The cumulative effect of these issues demonstrated a failure of the Governing Board and the Medical Staff to ensure compliance with all CoPs.

Based on interviews and review of records for inpatient and emergency care and services, and a review of employee immunization records, it was determined the hospital's governing body working with the medical staff did not implement and monitor policies and provision of care in the hospital in a manner to ensure the provision of quality health care in a safe environment.

Findings included:

1. The Governing Board (per interview and review of meeting minutes) was aware of the admission of an active TB (Tuberculosis) patient to the CAH's inpatient unit. No actions were identified or implemented to ensure safety of staff working in the CAH. This failure resulted in an Immediate Jeopardy situation (see C0270 for details).

2. The Governing Board failed to ensure compliance with the Condition of Participation (CoP) for Emergency Services at 42 CFR § 485.618 (C0200). Staffing patterns did not ensure qualified ED staff with appropriate specialized training and experience in emergency care were available to respond to emergency needs of patients. Review of meeting minutes showed the Governing Board was aware of staffing patterns and shortages but no definitive actions were taken to improve staffing on a consistent and sustainable level.

The Governing Board, who has the legal responsibility to ensure delivery of quality health care in a safe environment, failed to maintain compliance with the mandated Conditions of Participation.

Based on interviews and review of records for inpatient and emergency care and services, and a review of employee immunization records, it was determined the hospital's medical staff failed to provide appropriate medical direction and medical supervision for the CAH's health care activities to ensure the provision of quality health care in a safe environment.

Findings included:

Review of Medical Staff Meeting Minutes from January 2014 through the 8/8/2014 Federal CMS survey showed medical staff (working with the governing board) was responsible for the functionality of the hospital and adequacy of staff and medical services.

1. The Medical Staff failed to ensure the CAH provided an adequate system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel. (See Condition of Participation (CoP) for Provision of Services at 42 CFR § 485.635 (C0270)). Although the medical staff (per interview and review of meeting minutes) was aware of the admission of an active TB (Tuberculosis) patient to the CAH's inpatient unit, no actions were identified or implemented to ensure safety of staff working in the CAH. This failure resulted in an Immediate Jeopardy situation (see C0270 for details).

2. Additionally the medical staff failed to ensure compliance with the CoP for Emergency Services at 42 CFR § 485.618 (C0200). The failure involved identifying and implementing a staffing pattern to ensure qualified staff with appropriate specialized training and experience in emergency care were available in sufficient numbers to respond to emergency needs of patients.

Based on interviews and record review, the facility failed to:

1. Have a system in place to ensure that all employees had initial (new employee) and annual Tuberculin Skin Testing (TST - a test to check if a person has been infected with Tuberculosis bacteria). A review of 59 random employee immunization record print-outs revealed 20 employees with no current TSTs, nine (9) employees had no TSTs, and two (2) employees had positive TSTs without documentation of a current chest x-ray or indication of treatment.

This system failure was further impacted by the fact that on 04/18/2014 the facility admitted a patient with active Tuberculosis (TB). The patient was being followed and treated in coordination with the State of Montana and the Mayo Clinic for active TB.

This failure represented an Immediate Jeopardy (IJ) situation. On 08/07/2014 at 11:45 AM, an IJ was declared regarding infection control (a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel). Refer to C0278.

2. To ensure that nursing staff developed and kept current interdisciplinary nursing care plans, including coordination of a multi-disciplinary discharge plan for each patient. Refer to C0298.

These failures placed the patients and personnel at risk for adverse outcomes. The cumulative effect of these system failures resulted in the inability of the Critical Access Hospital (CAH) to comply with the mandated Condition of Participation: Provision of Services.

Based on interviews, observations and record review, the facility failed to follow infection control policies to protect patients, staff, and visitors as evidenced by the lack of a system to ensure that all employees had initial (new employee) and annual Tuberculin Skin Testing (TST - a test using purified protein derivative (PPD) to check if a person has been infected with Tuberculosis bacteria).

This failure represented an Immediate Jeopardy (IJ). On 08/07/2014 at 11:45 AM, an IJ was declared regarding infection control (a system for identifying, reporting, investigating, and controlling infections and communicable diseases of patients and personnel). Refer to C0270.

Findings Include:

1. On 08/06/2014, 59 random employee files were selected from an 08/04/2014 employee list provided by the facility. The employee list included full-time, part-time, and temporary employees.

2. On 08/06/2014 at approximately 3:00 PM, the "Official Immunization Record" print-outs were provided by the Infection Control Coordinator (ICC) for the 59 randomly selected employees. The ICC indicated the facility did not currently have an employee health person. She further indicated the immunization records did not appear to be complete.

3. After reviewing the 59 immunization records it was determined the following records lacked complete information regarding these employees' TB status:

a. Twenty (20) employees had no current TSTs recorded:

- Employee E4's last recorded TST was 1982
- E18's last recorded TST was 1992
- E23's last recorded TST was 1995
- E3, E6, E22, and E25's last recorded TST was 2005
- E17 and E24's last recorded TST was 2009
- E5, E7, E15, E13, and E19's last recorded TST was 2010
- E9's last recorded TST was 2011
- E8's last recorded TST was 2012
- E10, E11, E16, and E20's last recorded TST was 2013

b. Nine (9) employees (E27, E28, E29, E31, E32, E33, E34, E35, and E36) had no TST recorded.

c. Two (2) employees had previous positive TST recorded but no additional documentation. Employee E1's record indicated a positive TST in January 1976 (38 years ago); however, there was no current chest x-ray on file or documentation of TB treatment. Employee E2's record indicated that the employee had a positive TST in 1998 and again in 2001 (13 years ago); however, there was no current chest x-ray on file or any other documentation regarding chest x-ray or treatment.

4. The facility's policy and procedure titled, "Immunization Program" dated 05/28/2014 indicated the policy was "designed to protect employees and patients from transmitted diseases." The procedure indicated that "Healthcare workers, because of contact with patients, are at risk for some infectious diseases. Patients are vulnerable and must be protected as much as possible from infectious diseases that may be spread by healthcare workers."

Under the "Tuberculosis Screening Tests (PPDs)" section the facility's policy further indicated that "Screening and prophylactic treatment is offered in accordance with guidelines published by the IHS [Indian Health Services], CDC [Centers for Disease Control and Prevention], and the American Thoracic Society (ATS)...An annual Medical screening of healthcare workers will be reviewed for symptoms and updated in the employee record...All employee health related tests and treatment (PPDs, prophylaxis, chest x-ray, etc.) would be documented in the EHR [electronic health record]."

5. The Centers for Disease Control and Prevention (CDC) on their webcourse, "TB 101 for Health Care Workers" indicate that people at high risk for TB infection includes "Health care workers who serve clients who are at increased risk for TB disease." The information indicated that people who were at a higher risk for developing TB are persons who have a history of untreated or inadequately treated TB disease, persons with diabetes, chronic renal failure, leukemia, lymphoma, or cancer (head, neck, and lungs), persons who weigh less than 90% of their ideal body weight, cigarette smokers, and person who abuses drugs and/or alcohol. All of these high risk people are commonly seen in the CAH/hospital setting.

The CDC (Division of Tuberculosis Elimination) recommended that a health care worker who is considered at "medium risk" should receive a TST baseline (at hire) then annually. The CDC further recommends that if an employee's baseline TST is positive or who has a recent conversion to a positive TST should receive a chest x-ray to rule out active TB disease. These guidelines further indicated that when testing health care workers it is important to keep testing results for future reference.

6. Patient #21 was admitted on 04/18/2014 with diagnoses that included active pulmonary TB with cavitary lesions, diabetes, alcohol dependency, history of prostate cancer, and cachexia (weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease) with a 65 pound weight loss. Both nursing staff and management staff indicated that the State of Montana and the Mayo Clinic (Denver) were involved in the patient's TB treatment.

a. A Nurse's Note Addendum dated 04/18/2014 at 5:12 PM, revealed the following, "Patient arrived to reverse isolation...Patient placed on airborne precautions upon arrival."

b. During the tour of the inpatient unit on 08/04/2014 at approximately 1:30 PM, the patient was observed to still be in airborne isolation precautions due to TB.

c. Patient #21's TB therapy included four medications:

- Ethambutol (eliminates certain bacteria that cause TB) 400 milligrams (mgs) every morning;

- Isoniazid (for the treatment of tuberculosis TB) 300 mgs daily;

- Pyrazinamide (kills or stops the growth of certain bacteria that cause tuberculosis TB) 1000 mgs every morning; and

- Rifampin (used together with other medicines to treat tuberculosis TB) 600 mgs every morning.

7. According to the Clinical Director on 08/06/2014 at 4:25 PM, Patient #21 had not yet had a negative sputum since the start of his treatment. The latest sputum culture had been sent to the Mayo Clinic and the results were pending.

8. On 08/07/2014 at 11:45 AM, the survey team discussed the facility's incomplete employee TB information with the CEO, Clinical Director, Acting Director of Nursing, Quality Assurance Coordinator, and the ICC. At this time, the facility management team was made aware that an Immediate Jeopardy (IJ) issue existed because of this system failure.

9. On 08/08/2014 at approximately 8:30 AM, the facility management staff provided a print-out of the current TST status for all current 195 facility staff members. The facility identified the following:

a. Sixty-five (65) employees had no current TSTs recorded:

- One (1) employee's last recorded TST was 1980
- One (1) employee's last recorded TST was 1987
- One (1) employee's last recorded TST was 1993
- One (1) employee's last recorded TST was 1995
- Two (2) employees' last recorded TST was 1996
- One (1) employee's last recorded TST was 1998
- One (1) employee's last recorded TST was 2001
- One (1) employee's last recorded TST was 2002
- One (1) employee's last recorded TST was 2003
- Two (2) employees' last recorded TST was 2005
- One (1) employee's last recorded TST was 2007
- Three (3) employees' last recorded TST was 2009
- Six (6) employees' last recorded TST was 2010
- Three (3) employees' last recorded TST was 2011
- Nine (9) employees' last recorded TST was 2012
- Thirty (30) employees' last recorded TST was 2013

b. Fourteen (14) employees had no TST recorded.

c. Eleven (11) employees had previous positive TST recorded but no additional documentation. The TB status of these employees included the following:

- One (1) employee had a positive TST recorded in 1961
- One (1) employee had a positive TST recorded in 1968
- One (1) employee had a positive TST recorded in 1969
- One (1) employee had a positive TST recorded in 1971
- One (1) employee had a positive TST recorded in 1988
- One (1) employee had a positive TST recorded in 1995
- One (1) employee had a positive TST recorded in 1997
- Two (2) employees had a positive TST recorded in 1998
- One (1) employee had a positive TST recorded in 2004
- One (1) employee had a positive TST recorded in 2006

d. Three other employees that had a history of positive TST had chest x-rays taken during the survey after the system failure was identified. The TB status of these employees were as follows :

- One (1) employee had a positive TST recorded in 1976
- One (1) employee had a positive TST recorded in 1993
- One (1) employee had a positive TST recorded in 2001

The cumulative effect of the facility's failure to follow infection control policies for identifying, reporting, investigating, and controlling infections and communicable diseases and to follow the CDC's Tuberculosis guidelines placed all patients, personnel, and visitors at risk for an adverse outcome. See C0270.

Based on interviews and record review, the facility failed to ensure that nursing staff developed and kept current interdisciplinary nursing care plans and coordinated a multi-disciplinary discharge plan for each patient. This failure had the potential to lead to incomplete care and/or duplicate services. Refer to C0270. This failure was evident in four (4) of four (4) inpatient records reviewed.

Findings include:

1. The facility's policy entitled, "Inpatient Care Plan" dated March 2014 indicated that patient's plan of care and goals were developed with the patient and/or family and should reflect individualized care and treatment. The policy also indicated that a nursing plan of care should include patient-specific priority problems, short-term goals and measurable outcomes, interventions, nursing summary reflecting response to care interventions, and nursing plan priorities changes and recommendations.

2. Patient #21 was admitted on 04/18/2014 with diagnoses that included active pulmonary tuberculosis (TB) with cavitary lesions, diabetes, alcohol dependency, history of prostate cancer, and cachexia (weight loss, wasting of muscle, loss of appetite, and general debility that can occur during a chronic disease) with a 65 pound weight loss. Both nursing staff and management staff indicated that the State of Montana and the Mayo Clinic (Denver) were involved in the patient's TB treatment.

a. As of 08/07/2014 the nursing care plan initiated for Patient #21 did not include a plan that addressed the patient's TB treatment and airborne precautions.

b. The nursing staff had indicated a care plan for "knowledge deficit related to disease process." However, the plan did not indicate what disease process just that the patient and his family would have an increased understanding of the "disease process/medical condition."

c. There was no plan of care initiated for the patient's diabetes or alcohol dependency. On the day of his admission a physician's progress note indicated the following:

- The "last ETOH (alcohol) was 2 weeks ago" and there were no signs or symptoms of withdraws.

- diabetes with proteinuria (The presence of excessive amounts of protein in the urine); out of control, HgA1c (a blood test that correlates with a person's average blood glucose level over a span of a few months) was nine (9).

3. Patient #22 was seen in the Emergency Department on 07/31/2014 for right leg swelling and pain. The patient was admitted to the Critical Access Hospital (CAH) for intravenous antibiotic therapy due to cellulitis (infection).

a. The Medical Screening Exam dated 07/31/2014 revealed diagnoses including seizure disorder and obesity. The patient was also identified as being a newly diagnosed diabetic and required insulin.

b. There were no care plans initiated for Patient #22's seizure disorder or the newly diagnosed diabetes.

c. Patient #22 was admitted for intravenous antibiotic therapy and wound care. The patient's Inpatient Nurse Admission Assessment indicated that the patient would require assistance with wound care or dressing changes after discharge. There was no discharge care plan initiated for discharge planning.

4. Patient #24 was admitted on 08/06/2014 for intravenous antibiotic therapy and wound care. The patient's Inpatient Nurse Admission Assessment indicated that the patient would require assistance with wound care or dressing changes after discharge.

a. There was no care plan initiated for discharge planning for patient #24.

b. Patient #24's History and Physical dated 08/04/2014 indicated the patient abused alcohol and had a history of drug use. The patient also had a history of drinking rubbing alcohol and Lysol. The patient was released from jail so he could be treated for right hand cellulitis due to a self-inflicted human bite. Laboratory studies showed the patient was positive for Methicillin-Resistant Staphylococcus aureus (MRSA-a bacterium responsible for several difficult-to-treat infections in humans). The resident was admitted for intravenous drug therapy. The patient was placed on isolation precautions (contact) due to the MRSA. There was no care plan initiated for the contact isolation or the behaviors associated with the patient's alcohol and drug abuse.

5. Patient #25 was initially seen in the CAH's Emergency Department on 07/26/2014 after a fall at home. Due to the injuries (left side rib fractures and clavicle fracture) and a pneumothorax (collapsed lung) the patient was transferred to another facility. According to a chart review and staff interviews when the patient was ready to be discharged from the other facility, the patient had no one to assist him at home. Therefore, the patient was transferred back to the CAH on 08/01/2014.

a. The patient's diagnoses included diabetes that required insulin. There was no care plan initiated for the patient's diabetes (insulin dependent).

b. The Inpatient Nurse Admission Assessment (dated 08/01/2014), under the Discharge Planning section, indicated the patient's current living arrangements included stairs; no electricity; lived alone; needed help with shopping, cooking, and home maintenance; and the patient was unable to care for himself under the present conditions. There was no care plan initiated for discharge planning.

c. Patient #25 was interviewed on 08/06/2014 at approximately 10:00 AM. The patient indicated that he would be going home the next day. When asked about arrangements he stated he did not have any help at home but thought "they" [the CAH staff] were going to help him. The patient was unaware of the specific arrangements made regarding his discharge.

d. Review of the electronic health record for Patient #25 revealed a "Behavioral Health Discharge Planning" social service (SS) note dated 08/04/2014. The note indicated that "You may not VIEW this COMPLETED BEHAVIOR HEALTH DISCHARGE PLANNING."

6. In an interview with the Acting Director of Nursing (ADON) on 08/06/2014 at 3:10 PM, she indicated that significant care issues should be care planned. When asked about isolation precautions and significant diagnoses, the ADON indicated that these things should also be care planned.

7. An interview with a Licensed Nurse (LN #10) on 08/06/2014 at approximately 8:20 AM he/she indicated that the nursing staff did not initiate a care plan for discharge. LN #10 indicated that the only place the nursing staff documented any information regarding discharge planning was on the Inpatient Nurse Admission Assessment. If the patient's physician ordered something for after discharge such as oxygen, nursing would order it and document information about the ordered oxygen in the Nurse's Notes. LN #10 indicated the nursing staff were not able to read any Social Service (SS) notes because SS notes were all confidential.

8. LN #10 also explained that each morning the staff had interdisciplinary rounds that reviewed each patient's care and services. It was during these rounds that discharge planning was discussed. LN #10 indicated that each member of the disciplinary team who made rounds did their own documentation.

9. On 08/06/2014 at approximately 10:00 AM, the Acting Director of Nursing (ADON) stated that there was no coordinated discharge plan. She indicated that the interdisciplinary team made morning rounds but the information gathered from these rounds did not get documented into one plan. The ADON also acknowledged that the other disciplines; namely nursing did not have access to the Social Service documentation due to a privacy issue. She further acknowledged that nursing was unable to access any SS notes that were made regarding a patient's discharge planning.


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10. Review of the Service Unit Rounds Reports from June 1, 2014 through the days of the survey revealed these reports included discharge information for the patients in the inpatient unit but this information was not evident in any respective patient's discharge plans.

Based on interviews and record review, the facility failed to ensure all information scanned into the electronic medical record was accurate, complete, and authenticated.

Findings include:

A review of patient medical records began on 8/6/2014 at 8:30 AM. A request was sent to the Medical Records department to obtain ED records of patients who received Emergency services. The following patient records are a sample of the findings.

1. Patient #1 arrived in the ED seeking emergency care on 8/5/2014, but required a higher level of care for "specialized care cardiology." The paper records submitted to the Medical Records department for scanning were incomplete. The record included white typing paper with strips taped to the paper and labeled NIBP trends (noninvasive blood pressure readings). Also taped to the same piece of paper, but taped sideways, was a cardiac rhythm strip. Neither strip had any patient identifier such as name or medical record number. The hospital transfer form for Patient #1 was also incomplete. The patient's diagnosis, date, time, and RN signature were left blank.

2. Patient #2 arrived in the ED seeking emergency care on 8/5/2014 with a diagnosis including chest pain. The patient had arrived by ambulance or EMS.

a. An ambulance worksheet was attached to a 12-lead EKG strip. This half sheet had a transfer section completed but was illegible. On the top right hand corner of the form it read "Full Trip report will be faxed later." The Medical Record staff validated they were not aware of any other form for EMS services.

b. A second EKG strip was attached to the first strip with no patient identifiers.

c. The 'Medical Clearance Form' dated 8/5/2014 was also incomplete. Under item/section 6, the facility name, reason for presenting for medical treatment, the detention officer name and signature sections were left blank. At the bottom of the form, the acceptance of the inmate for readmission to the detention center by the detention officer was also left blank.

3. Patient #3 arrived in the ED on 8/5/2014 for injuries sustained in a rollover car accident and presented with neck, back, and lumbar pain. Patient #3 required transfer to a higher level of care for services not available at the facility. The 'Emergency Room Visit' form was incomplete. All sections were blank except for physician orders written under the section 'purpose of visit/problem list additions or changes.' The ambulance worksheet was left blank under the allergy, medications and transfer care sections. EKG strips were taped to white typing paper with no patient identifiers.

4. During an interview on 8/7/2014 at 11 AM, the Medical Records staff confirmed the ED records were sent to the department in loose paper forms. Some papers had patient identifiers but some papers had no patient identifiers. Staff indicated, "If identifiers are not confirmed by the ED, the forms cannot be scanned into the permanent medical record."

The Hospital failed to ensure that all services including the employee heath program regarding Tuberculin Skin Testing (TST) which affected patient health and safety was evaluated as part of the Quality Assurance Program.

Findings included:

Review of the employee health records showed many employees had no current TST. The hospital did not have an effective tracking system to ensure employees who were due for a required immunization were notified and received updated immunization(s). See C0270 for specifics.

Review of medical staff and Governing Board minutes did not show the Medical Staff or the Governing Board had reviewed QA data regarding employee immunizations.