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Based on record review and interview, the facility failed to document in the patients' medical record that notice of the facility's advance directives policy and procedure was provided at the time of admission or registration, and that education was provided if requested for 24 (#s 1-24) out of 43 sampled patients.
Findings include:

Review of the electronic medical record reflected documentation of a "yes" or "no" answer to the advance directive prompt in the facility electronic health care system window. No other documentation was made available for patients #1-24 in the sample that reflected patients were given an opportunity to compose an advanced directive if they answered "no". The medical record did not reflect patients were provided education about advanced directives. No other information was submitted prior to the exit of the survey.

In an interview on 6/22/16 at 2:45 p.m., staff member C stated the advanced directive information was in the old facility health care system program but was not carried to the new when there was an update. Staff member C stated the emergency department and surgery department patients were not given a handout of the patient rights and responsibilities or advanced directives as the facility posted signs of the patient rights in those departments.

In an interview on 6/22/16 at 3:07 p.m., staff member J stated patients are asked during registration, for inpatient and outpatient services, about their advanced directive. Staff member J stated she was not sure how this was handled in the emergency department. Staff member J stated she believed the surgery department handled advanced directives unless the patient was admitted to the floor as an inpatient.

Review of the facility policy and procedure titled Advance Directive, revised 7/2015, reflected the facility would inform and educate all adult patients concerning the right to accept or refuse the option to formulate an advanced directive.

Based on observation, interview and record review, the facility failed to ensure the grease traps on the grill were free from overflow grease accumulation. Findings include:

During an observation of the kitchen on 6/20/16 at 1:00 p.m., there was 1/2" to 3/4" of grease accumulation oozing out from the overflow grease traps, on each side, at the back of the grill.

During an interview on 6/20/16 at 1:07 p.m., staff member E stated the shift cooks were responsible for ensuring overflow grease traps were free from grease accumulation. He stated staff were required to clean the overflow grease build up prior to leaving their shift.

A review of the facility's Dietary Cleaning List, initiated 6/20/16, read, "3. Clean Grill and oven. Inside and out. Degrease sides and back."

A review of the facility's Cleaning Instructions: Ranges policy, revised on 5/12/14, read, "The cook on each shift is responsible for keeping the range as clean as possible during the preparation of the meal. The range will be cleaned after each use. Spills and food particles will be wiped up as they occur...3. Wipe the outside surface of the appliance using a sanitizing solution. 4. Wash the drip pans as needed and/or according to the cleaning schedule. 5. Spills should be cleaned up as they occur."

Based on observation, interview and record review, the facility failed to ensure all opened pre-packaged foods had an open date; failed to ensure all dry-goods opened within 30 days were used or disposed of, and failed to ensure a box containing rotten potatoes were not readily available for staff use. Findings include:

During an observation of the bulk dry-goods in the storage room on 6/20/16 at 1:36 p.m., there was an opened 10 lb. box of Orzo/Rosa Marina 100% Durum Semolina without an open date.

During an interview on 6/20/16 at 1:37 p.m., staff members D and E, stated kitchen staff were required to date items they had opened. The staff members stated all opened dry foods were required to be used within 30 days of the open date.

During an observation on 6/20/16 at 1:40 p.m., three opened and dated, 5 lb boxes of Krusteaz dry-bulk were available for staff use. Those boxes with opened dates were:
- One box was vanilla cream icing with an open date of 5/4/16
- One box of chocolate fudge icing with an open date of 4/27/16
- One box of Oat bran muffin with an open date of 12/2/15

During an observation of the walk-in fridge on 6/20/16 at 1:45 p.m., an opened cardboard box containing seventeen rotten potatoes was located at the rear of the walk-in fridge. Staff member D identified the potatoes as "Russets" and removed the box from the shelf. An opened clear bag, identified by staff member D as 1 lb of chopped lettuce, was sealed with a twist tie on a top shelf. The bag did not have an open date. An opened clear bag, identified by staff member D as 1 lb of corned beef sandwich slices, was on a bottom shelf. The bag did not have an open date.

During an interview on 6/20/16 at 1:47 p.m., staff member D stated kitchen staff were required to set aside rotten/spoiled foods so the distributor could credit the hospital or replace the items. She stated staff were required to date all opened bags to ensure foods were not used beyond the three days.

A review of the facility's Food Storage policy, revised on 5/12/14, page 91, read, "13. Left over good is stored in covered containers or wrapped carefully and securely. Each item is clearly labeled and dated before being refrigerated. Leftover food is used within 3 days or discarded."

Based on observation, interview and record review, the facility failed to ensure that patient medications and biologicals were stored in accordance with accepted professional principles. Specifically, staff were storing personal food items in the refrigerator where patient medications were stored. Findings include:

During an observation on 6/22/16 at 10:20 a.m., the pharmacy refrigerator contained patient medications on the shelves and personal food in the door. The following items were stored in the door:
- One sandwich bag with three slices of moldy cantaloupe
- One opened 14 oz bag of sour cream
- One opened 12 oz bottle of French dressing
- One opened 12 oz bottle of Italian dressing
- One 12 oz bottle of diet coke
- One 12 oz bottle of cherry coke
- Two Swiss Miss Pudding cups
- One opened 4 oz bottle of lemon juice
- One 12 pack bag of string cheese
- Two sandwich bags with apple slices
- Two 11 oz bottles of Adkin shakes
- One opened 18 oz bottle of KC Masterpiece BBQ sauce
- One opened 8 oz box of cream cheese
- One 1/2 gallon of milk

Stored in the freezer section of the refrigerator were:
- One Swanson's turkey pot pie
- One box of chicken taquitos

During an interview on 6/22/16 at 11:15 a.m., staff member C stated the pharmacy staff had been instructed on previous occasions to only store patient medications and biologicals in the pharmacy refrigerator.

During an interview on 6/22/16 at 11:45 a.m., staff member F stated only food belonging to the pharmacy staff were stored in the pharmacy refrigerator/freezer. He stated the pharmacy is also surveyed by the Montana Board of Pharmacy and no one has ever mentioned their personal food in the medication refrigerator.

During an interview on 6/22/16 at 11:50 a.m., staff member F stated all food would be stored in a designated refrigerator/freezer from that date forward. He stated only patient medications and biologicals would be stored in the pharmacy refrigerator.

A review of the facility's Pharmacy Refrigerator Med [sic] List, revised on 12/15/15, listed thirty-eight patient medications that were stored in the pharmacy refrigerator. One medication was kept in the freezer.

A review of the facility's Medication Storage/Environmental control policy, revised on 2/12/10, read, "Appropriate temperature...3. Medication refrigerators shall not be used to store food."

Based on record review and interview, the facility failed to maintain a list of all services furnished under arrangements or agreements, and failed to monitor all arrangements or agreements to ensure they were not expired or terminated. This has the potential to affect all patients of the CAH. Findings include:

On 6/20/16 at 12:45 p.m., a request for a copy of a current list of services provided by contract/agreement, including scope and nature of contract/agreement, was submitted to staff member A. On 6/20/16 at 3:40 p.m. staff member A stated the facility did not keep a list of all of the facility contracts. Staff member A handed the surveyor the current hard copy of all contracts for the facility.

A review of the facility contracts reflected two contracts that had not been renewed. The linen rental and service agreement, entered into on 11/1/08, had an expiration date of 11/1/14. The medical waste services agreement, entered into on 6/1/09 with a 60 month term of agreement, was expired in 2014.

During an interview on 6/23/16 at 8:00 a.m., staff member B was informed of the expired contracts.

During an interview on 6/23/16 at 1:15 p.m., staff member B reported there were no renewals done for the expired linen and medical waste contracts. Staff member B stated the contracts were expired. Both services were still continuing to be conducted during the survey.

Based on staff interview, review of the patient medical record and review of the facility policies and procedures, the facility failed to ensure the medical record system allowed prompt retrieval by staff 24 hours a day, 7 days a week (C-0301), failed to ensure the electronic medical record was complete and readily available (C-0302), the designated member of the staff for maintaining the electronic medical record failed to ensure that records were complete, accurately documented, and readily accessible (C-0303), failed to ensure a discharge summary was completed and available in the medical record (C-0304), and failed to ensure authentication of the entry of the physician's order was timed and noted as correct (C-0307).

The cumulative effect of the failed standards resulted in the facility not being able to provide a comprehensive accurate medical record system that enabled staff to retrieve an accurate, complete and readily available medical record for staff and patient needs.

Based on record review and interview, the facility failed to ensure the medical record system allowed prompt retrieval by staff 24 hours a day, 7 days a week. Specifically, during the survey process retrieval of the patient medical record was delayed due to the medical system program and staff access rights. Findings include:

On 6/22/16 at 2:30 p.m., the surveyors conducted an electronic record review for the survey sample. During the record review, staff member B, C and J assisted the surveyors through the facility electronic medical record program.

During the record review, staff members B, C and J had different access to the medical record allowing some windows to be reviewed and access to others were locked or not seen at all.
Listed below are areas that staff members B, C and J had differing access to, which caused a delay in the survey process;
-initiation of the care plan;
-initiation of the discharge summary;
-documentation of notification of patient rights;
-documentation of patient education regarding advanced directives;
-and documentation that the grievance process was explained and made available to patients.

The record review took several hours as the medical record program had several windows to open to retrieve the above medical record areas. The surveyors were required to review the hard copy paper records the following day, once facility staff were able to find a more succinct way to open the medical record "windows" in each section/area.

On 6/23/16 at 1:15 p.m., staff member B showed the surveyor the windows that would need to have a screen shot taken to show interventions and goals for the care plan. Staff member B stated the process would produce a large volume of copies. Several windows were required to be opened in order to view the above listed items.

During the exit on 6/23/16 at 5:50 p.m., staff member B stated the best way to review the medical record is to open every single item in the program. The survey team reported to administration this process was a hinder to the timeliness of the survey process.

Based on record review and interview, the facility failed to ensure the electronic medical record was complete and readily available for 24 (#s 1-24) of 43 sampled patients. Findings include:

1. A review of the patient's medical records on 6/22/16 from 2:00 p.m.- 6:00 p.m. reflected no documentation for patients #1-24 that reflected patients were given information about patient rights, advanced directives or how to report a grievance.

The record review took several hours as the medical record program had several windows to open to retrieve the above medical record areas. The surveyors were required to review the hard copy paper records the following day, once facility staff were able to find a more succinct way to open the medical record "windows" in each section/area.

On 6/23/16 at 1:15 p.m., staff member B showed the surveyor the windows that would need to have a screen shot taken to show interventions and goals for the care plan, and one question with a "yes" or "no" answer for advanced directive history. Staff member B stated the process would produce a large volume of copies. Several windows were required to be opened in order to view the above listed items.

No other documentation was submitted prior to the exit that reflected the patient medical records contained information for each patient's rights, advanced directives or how to report a grievance. No facility policy was submitted to the survey team prior to exit regarding patient instruction for how to report a grievance.

Based on interview and record review, the designated member of the staff for maintaining the electronic medical record failed to ensure that records were complete, accurately documented, and readily accessible. Findings include:

During an interview on 6/23/16 at 4:30 p.m., staff member I stated she was responsible for ensuring physicians completed medical records within thirty (30) days.

A review of the facility Bylaws, Rules and Regulations, revised 8/2010, pages 30 and 31, read, "Section 3. Medical Records...3... All medical records should be completed for filing within thirty (30) days of discharge...B. At the end of the thirty (30) day period, if the medical record is not complete, the Medical Record Technician will notify the hospital administrator of the incomplete record."

Refer to § 485.638(a)(4) C-0304

Based on observation, interview and record review, the facility failed to ensure the designated professional staff maintained a complete medical record for 14 (#s 26, 27, 28, 30, 31, 32, 34, 35, 36, 38, 40, 41, 42, and 43) of 43 sampled patients. Specifically, medical records lacked evidence of admission orders, diagnosis, a patient history, a patient physical, an operative note, a pathology report, discharge summary, consultation, summary notes and/or records from other treating facilities. Findings include:

During an observation on 6/20/16 at 2:10 p.m., folders with a specific physician's name on the cover were on shelves inside the medical records department. Inside each folder were Missing Report documents with specific missing information for the patient's medical records.

During an interview on 6/21/16 at 2:20 p.m., staff member J stated when a missing portion of the medical record is identified by the medical records department, the physician is notified. A technician was required to fill out a Missing Report form and put it into the corresponding physician's name so he/she can complete. The staff member stated a medical record is considered incomplete until the physician completes all missing information.

1. Patient #26 was admitted to the hospital on 9/22/14 and discharged on 9/25/14.

A review of the Missing Reports document lacked admission orders from staff member L. The patient's medical record was incomplete.

2. Patient #27 was admitted to the hospital on 10/1/14 and discharged on 10/3/14.

A review of the Missing Reports document lacked a diagnosis from staff member L. The patient's medical record was incomplete.

3. Patient #28 was seen at the hospital on 8/18/14 and not admitted.

A review of the Missing Reports document lacked a patient history and physical, and operative and pathology reports from staff member L. The patient's medical record was incomplete.

4. Patient #30 was admitted to the hospital on 3/29/16 and discharged on 4/5/16.

A review of the Missing Reports document lacked admission orders from staff member M. The patient's medical record was incomplete.

5. Patient #31 was admitted to the hospital on 3/11/16 and discharged on 3/17/16.

A review of the Missing Reports document lacked another treating facility records to complete the medical records. The patient's medical record was incomplete.

6. Patient #32 was admitted to the hospital on 3/10/16 and discharged on 3/11/16.

A review of the Missing Reports document lacked discharge orders from staff member M. The patient's medical record was incomplete.

7. Patient # 34 was admitted to the hospital on 2/29/16 and discharged on 3/4/16.

A review of the Missing Reports document lacked discharge orders from staff member O. The patient's medical record was incomplete.

8. Patient #35 was admitted to the hospital on 4/28/16 and discharged on 5/3/16.

A review of the Missing Reports document lacked discharge orders from staff member O. The patient's medical record was incomplete.

9. Patient #36 was admitted to the hospital on 6/21/15 and discharged on 6/23/15.

A review of the Missing Reports document lacked a diagnosis from staff member P. The patient's medical record was incomplete.

10. Patient #38 was admitted to the hospital on 10/5/15 and discharged on 10/9/15.

A review of the Missing Reports document lacked physician's consultation notes. The patient's medical record was incomplete.

11. Patient #40 was admitted to the hospital on 1/13/16 and discharged on 1/13/16.

A review of the Missing Reports document lacked a Labor and Delivery summary from staff member R. The patient's medical record was incomplete.

12. Patient #41 was admitted to the hospital on 5/16/14 and discharged on 5/22/14.

A review of the Missing Reports document lacked a signed history and physical from staff member L. The patient's medical record was incomplete.

13. Patient #42 was admitted to the hospital on 12/3/13 and discharged on 12/18/13.

A review of the Missing Reports document lacked a signed history and physical from staff member L. The patient's medical record was incomplete.

14. Patient #43 was admitted to the hospital on 2/4/14 and discharged on 2/9/14.

A review of the Missing Reports document lacked a signed history and physical from staff member L. The patient's medical record was incomplete.

During an interview on 6/23/16 at 3:55 p.m., staff member I stated staff member L had not been employed by the hospital since 2014 and he had left the committee. Staff member I stated she was responsible for ensuring accurate medical records were completed by the medical staff within 30 days. She stated she was aware that some medical records lacked information and therefore were incomplete. She stated the Chief of staff, when notified, should have been ensuring medical records were complete and accurate in a timely manner. Staff member I stated she had not begun the process of updating the Chief of staff of delinquent records, but would do so immediately.

During an interview, just prior to the exit conference on 6/23/16 at 4:45 p.m., staff member I stated she was responsible for updating the Chief of staff regarding missing or incomplete records. The staff member stated she should have been providing the Permanent Incomplete Record to the Chief of Staff for incomplete medical records.

A review of the facility's Permanent Incomplete Records showed medical records staff were required to identify and document the reason the designated professional staff did not complete the medical record. This document was to be provided to the Chief of staff for review and completion.

A review of the facility Bylaws, Rules and Regulations, revised 8/2010, pages 30 and 31, read, "Section 3. Medical Records...2. A Medical and Physical Examination shall be done no more than thirty (30) days before or forty-eight hours after an admission of the patient. 3. At the time of discharge, the attending physician shall see that the medical record is as complete as possible. All medical records should be completed for filing within thirty (30) days of discharge...B. At the end of the thirty (30) day period, if the medical record is not complete, the Medical Record Technician will notify the hospital administrator of the incomplete record. The hospital administrator will notify the Chief of the Medical Staff on that day, if possible and they both will sign and send a letter to the staff member who is delinquent with his/her charts, notifying the physician that he/she has seven (7) calendar days in order to complete the delinquent records. If, at the end of the seventh (7th) calendar day, the records are not completed, then the physician will have his/her admitting privileges automatically suspended until all delinquent records are completed."

Based on record review and interview, the facility failed to ensure the timing of the physician entry was noted for 2 (#s 25 and 36) out of 43 sampled residents. Findings include:

1. A review of the medical record for patient #25 reflected the physician's admission order, dated 6/22/16, did not reflect the time of the entry.

In an interview on 6/22/16 at 2:30 p.m., staff member C stated the order was scanned in and if there was no time entered on the form it had not been done.


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2. Patient # 36 was admitted to the hospital on 6/21/15 and discharged on 6/23/15.

A review of the Missing Reports document lacked evidence of a discharge time and diagnosis from staff member P. The patient's medical record was incomplete.

A review of the facility Bylaws, Rules and Regulations, revised 8/2010, pages 30 and 31, read, "Section 3. Medical Records...3. At the time of discharge, the attending physician shall see that the medical record is as complete as possible. All medical records should be completed for filing within thirty (30) days of discharge...B. At the end of the thirty (30) day period, if the medical record is not complete, the Medical Record Technician will notify the hospital administrator of the incomplete record. The hospital administrator will notify the Chief of the Medical Staff on that day, if possible and they both will sign and send a letter to the staff member who is delinquent with his/her charts, notifying the physician that he/she has seven (7) calendar days in order to complete the delinquent records. If, at the end of the seventh (7th) calendar day, the records are not completed, then the physician will have his/her admitting privileges automatically suspended until all delinquent records are completed."

Based on record review and interview, the facility failed to implement the facility abuse and neglect policy and procedure to ensure all staff received training and had knowledge of how to recognize elder abuse for all swing bed patients in the facility. Findings include:

During an interview on 6/23/16 at 10:25 a.m., staff member C stated all direct care staff were required to attend monthly staff meetings. She stated staff members that did not attend the meetings were required to read the meeting minutes and initial their name when they were done reading. She stated staff members that did not read the meeting minutes would be reminded to read the meeting minutes.

During an interview on 6/23/16 at 8:20 a.m., staff member H was not able to give the definition of abuse. She sated she had not been provided abuse training by the hospital.

During an interview on 6/23/16 at 8:45 a.m., staff member U was not able to give the definition of abuse. She stated it had been more than 5 years since she was provided abuse training by the hospital.

During an interview on 6/23/16 at 9:25 a.m., staff member G was not able to give the definition of abuse. She sated she had not been provided abuse training by the hospital.

During an interview on 6/23/16 at 9:35 a.m., staff member T was not able to give the definition of abuse. She stated she had not been provided abuse training by the hospital.

On 6/23/16 at 3:00 p.m., surveyors requested training records regarding abuse, specifically for direct care staff, including maintenance and housekeeping. Information was not provided.

On 6/23/16 at 4:30 p.m., monthly staff meeting minutes, dated 3/24/16, were provided. The minutes did not mention abuse training.

During an interview on 6/23/16 at 5:31 p.m., staff member C stated staff member G had not read the meeting minutes. Staff member C stated staff member T had read the meeting minutes and initialed she had done so.

During an interview on 6/23/16 at 1:15 p.m., staff member B was asked for a list of the dates of training for maintenance staff, housekeeping, volunteers, etc. regarding abuse and neglect. No other information was submitted to the survey team prior to the exit.

Review of the facility policy and procedure titled Abuse Reporting and Investigation, revised 11/30/15, reflected that, "all employees will review the Recognizing Elder Abuse document on hire and annually."