The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

MONTANA STATE HOSPITAL 100 GARNET WAY WARM SPRINGS, MT April 5, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on deficiencies cited, the facility failed to protect and promote the rights of 9 (#s 1, 5, 11, 12, 13, 14, 15, 16 and 17) of 17 patients admitted to the facility. Findings include:

The facility staff did not review and resolve grievances for 8 (#s 1, 5, 12, 13, 14, 15 , 16, and 17) of 8 patients lodging grievances. (See A123).

The facility staff did not protect the patients privacy and dignity for 1 (#11) of 17 sampled patients. (See A143).

The facility staff did not protect the patients from abuse and harassment for 3 (#s 1, 5 and 11) of 3 allegations of abuse. (See A145).
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, policy review, and staff interview, the hospital failed to provide a written notice of its resolution for grievances received from 8 (#s 1, 5, 12, 13, 14, 15 , 16, and 17) of 8 patients lodging grievances. Findings include:

1. On 4/3/12 at 3:00 p.m.,. the policy titled Patient Grievance Procedure was reviewed by the surveyor. The following was documented on the policy:

Responsibilities:
A. "Patient Grievance Committee is responsible for reviewing and responding to patient grievances, and recommending actions within the context of this policy. The PGC is responsible for oversight and coordination of the Patient Grievance Procedure.
B. The Social worker staff is responsible for explaining the Patient Grievance Procedure and MSH Patient rights to each patient within a short time after admission. This may need to be repeated if the patent does not clearly understands the information when it is first presented.
C. All staff is responsible for maintaining the integrity of the grievance process and helping to resolve the patient complaints and disputes."

Procedure:
..."The PGC is responsible for enforcing the time frames and prescribed in the Patient Grievance Procedure.
-All grievances will be forwarded to the Patient Grievance Committee (PGC) for recording.
-Within seven days, the program manager or other individual designated by the PGC will address the issue through informal means in attempt for resolution.
-If a resolution is reached, both the Program Manager and the complainant will sign and date the grievance from as [sic] Asatisfied. The Team Leader will forward the grievance from to the Patient Grievance Committee. If a resolution can not be reached, the Program manager will forward the Patient Grievance Form, the Patient Grievance Action Form, and relevant documentation as necessary, to the PGC. The PGC will meet and discuss the grievance with in seven days. The complainant and the Program Manager will be notified in writing of the PGC decision.
-Written responses will be sent by the PGC to all individuals who submit grievances. The letter will include 1) decision that contains the name of the hospital contact person; 2)The steps taken on behalf of the patient to investigate the grievance; 3) The results of the grievance process; and 4) the date of completion."

2. Patient #1 was admitted to the facility on [DATE] and filed written grievances on 12/9/11 and 12/10/11. The QI department received the grievance on 12/13/12. The letter documented, "The steps taken regarding your grievance are as follows: 1. You had a meeting with [staff name] unit manager. 2. The committee met and discussed your grievance". It was further noted in the letter, "The committee will consider these matters resolved as of December 21, 2011 . . . " The letter was forwarded to the unit manager. The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

3. Patient #5 filed a grievance on 2/9/12. The QI department received the grievance on 2/23/12. A letter from the QI dated 3/2/12 documented, "The results of the grievance process are as follows: . . . A member of the committee will follow up with the program manager." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

4. Patient #12 was admitted on [DATE] and filed a written grievance on 1/29/12. The QI department stamped the grievance as received on 1/31/12. The patient was discharged on [DATE]. The patient had a mailing address. The resolution to the grievance was dated 2/8/12, three days after he was discharged . The letter was not mailed to the patient. The resolution letter documented, "NOTE TO FILE: "The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

5. Patient #13 was admitted on [DATE] and filed a written grievance on 1/25/12. The patient marked "not satisfied" with the resolution. The QI date stamped the grievance as received on 1/27/12. The patient was discharged on [DATE]. The resolution letter was not sent to the current mailing address. The resolution letter documented, "NOTE TO FILE: The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

6. Patient #14 was admitted on [DATE] and filed a written grievance on 1/27/12. The QI department date stamp was 2/9/12, which was two days after the patient was discharged on [DATE]. The resolution letter was not sent to the current mailing address. The resolution letter documented, "NOTE TO FILE: The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

7. Patient #15 was admitted on [DATE] and a written grievance was filed on 2/24/12, 2/26/12, and 2/28/12. The patient marked "not satisfied" on the grievances. The QI department date stamped all three separate grievances as received on 3/19/12 which was 19 days after the patient was discharged on 2/29/12. The resolution letter was not sent to the current mailing address. The resolution letter documented, "NOTE TO FILE: The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

8. Patient #16 was admitted to the facility on [DATE] and written grievances were filed on 2/24/12, 2/27/12, 2/28/12 and 3/12/12. These grievances were marked as not satisfied. The QI department date stamped all four separate grievances as received on 3/19/12. The patient was not discharged until 3/23/12. The resolution letter was not sent to the current mailing address. The resolution letter documented, "NOTE TO FILE: The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

9. Patient #17 was admitted to the facility on [DATE] and filed a written grievance on 3/5/12. The QI department received the grievance on 3/19/12, which was 10 days after the patient was discharged . The resolution letter was not sent to the current mailing address. The resolution letter documented, "NOTE TO FILE: The Patient Grievance Committee recently received a grievance from [patient's name]. [patient name] was discharged prior to the meeting. This matter is considered resolved." The letter lacked a resolution and the patient was not provided a chance to appeal the decision.

10. On 4/3/12 at 10:00 a.m., staff member F, the program manager for the Spratt unit, was interviewed on the grievance procedure. She stated that any patient can file a grievance. The grievance was to be sent to QI for review. She stated that she would attempt to resolve the issue if the grievance was sent back to her.

On 4/3/12 at 11:10 a.m., staff member A, the DON, stated that all grievances should have a resolution even if the patient was discharged . "I was not aware that this was not happening."

During an Interview with staff member E, the QI director, on 4/3/12 at 4:00 p.m., the surveyor was informed that resolution letters were not sent to patients who had discharged . A letter titled NOTE TO FILE was placed in the medical record. If patients were discharged before the QI completed the review, then it was possible a resolution would not be completed , and a letter titled NOTE TO FILE would be placed in the medical chart. The above patients were not mailed the resolution letter even though we had their address. "I was not aware we needed to do that." Further into the interview, the QI director stated that the grievance procedure was being revamped because it was taking to long for a grievance to be resolved. "I know my department is late on responding past the 7 days as stated in the policy."

During an interview on 4/4/12 at 10:00 a.m., the social worker stated that she was not involved in the grievance procedure unless the grievance was about her. She does not talk to patients regarding a grievance. "We are instructed to forward all grievances to the QI department."
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on staff interview, the facility failed to provide privacy relative to respect and dignity during personal hygiene for 1 (#11) of 17 sampled patients. Findings include:

On 4/4/12 at 9:30 a.m., during an interview with the unit manager, she indicated there was an allegation against staff member B by another staff person. The staff person had indicated that staff member B had verbally abused patient #11.

On 4/4/12 at 2:00 p.m., staff member A, the DON, was interviewed. he stated the allegation was not investigated to his knowledge.

On 4/4/12 at 2:15 p.m., staff member A supplied a copy of an email dated 1/27/12 from an RN staff member to the unit manager, "I observed some disturbing behavior by one of the Psych Techs from A Wing yesterday 1-26-12. At lunch time for A Wing, a patient [#11] came out of the dining area into to Rotunda and went into the restroom. PT, [staff member B] came out of the dining area and held open the restroom door and shouted, ([patient #11] are you in there sticking your finger down your throat again? Yeah that's what I thought!). Then without going in to see if the patient was alright she left. There was no indication of sensitivity or for the privacy of the patient or her condition. There were several people in the Rotunda eating lunch and the exchange was plainly overheard by all sitting at the table . . . " The unit manager then forwarded the email to the DON with the following, "I addressed this with [staff member B]. She did apologized [sic] to this patient. These issues seem to surface with this staff person. Informed her the next complaint or issue would be addressed with your involvement. She is aware that such behavior could result in termination".

The staff member continued to work on the unit with patient #11.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
Based on record review and staff and patient interviews, the facility failed to ensure that patients were free from all forms of abuse or harassment for 3 (#s 1, 5 and 11) of 3 reviewed abuse allegations. Findings include:

1. In the Allegations of Abuse or Neglect Policy, under section II, the policy reads: "All patients have the right to be free from abuse or neglect as well as fear of being abused or neglected. Allegations or information indicating that abuse or neglect may have occurred will be thoroughly and promptly investigated with appropriate follow-up action taken." Under section V, the policy reads: "The investigation process begins when a Nursing Supervisor, the Director of Nursing, the Hospital Administrator, the Medical Director, or the Director of Quality Improvement receives information that abuse or neglect may have taken place . . . The receipt of information triggers a process for taking action to protect patients and employees and collecting information to determine facts that will either substantiate a finding that abuse or neglect took place or lead to the conclusion that it did not . . . "

2. On 4/3/12 at 10:00 a.m., the patient grievances were obtained from the facility.

A. On 12/10/11, patient #1 wrote on a Patient Grievance Form, "[staff member B] a day/weekend staff member 1) Called me a retard. (verbal abuse) 2) said needed to be committed to the hospital so she could do what she wanted to do to me. 3) [staff member B] would not tell me who the lead for the Saturday day shift is. (neglect) 4) [staff member B] said if it was up to her, I would not receive my canteen [privileges]. (verbal abuse) . . . "

The Patient Grievance Action Form, dated 12/12/11 and signed by staff member D, unit manager, documented, "Angry with PT staff. RN and myself met with [staff member B] the PT - [staff member B] denied allegation".

Attached to the grievance form was a letter addressed to the patient from the facility grievance committee dated 12/21/11. The letter documented, "The steps taken regarding your grievance are as follows: 1. You had a meeting with [staff name] unit manager. 2. The committee met and discussed your grievance". It was further noted in the letter, "The committee will consider these matters resolved as of December 21, 2011 . . . " The letter was forwarded to the unit manager.

On 4/3/12 at 10:15 a.m., staff member A, the DON, was interviewed. He stated he was unaware that patient #1 had made an allegation of abuse towards a staff person. He stated that there had been issues with staff member B and he was not surprised by the allegation. Staff member A stated the allegation was not being investigated to his knowledge.

On 4/4/12 at 9:30 a.m., staff member D, unit manager,, was interviewed. She stated she did speak with the staff person regarding the incident and staff member B denied the allegation. She did not remember if she had given the information to the DON or the administrator. When asked if she had any other allegations against staff member B, she stated yes, and that it was being investigated by the DON.

The allegation had not been investigated per the facility policy.

B. On 12/10/11, patient #1 wrote on a Patient Grievance Form, "I enjoyed my first lunch in the cafeteria, but was unaware of the 2 drink/cup policy per person. I got "called out" and embarrassed for not knowing. This rule is difficult for "new kids on the block", to grasp - especially without knowing. I hate to be penalized for something I did not know . . . "

On 4/3/12 at 12:20 p.m., patient #1's record was reviewed. The patient was on a regular diet with no restrictions. On 12/10/11 at 8:20 a.m., the psych tech wrote, "Pt went to dining hall. Pt filled tray of 7 fluids when this writer told pt that there was a limit to two fluids and that he needed to put some of them back. Pt became very argumentative and non redirectable. Did not listen to anything staff asked. When told he would be staying on the unit for lunch because of his behavior and not following dining room rules . . . " At 9:50 a.m., the RN wrote, "Staff reported that [patient #1] had been not following dining room rules and would not follow staff direction. Placed on unit . . ."

The Welcome handbook for A wing was reviewed on 4/3/12 at 10:00 a.m. There was no mention of a 2 drink rule.

On 4/3/12 at 10:15 a.m., staff member A, the DON, was interviewed. He stated there was no policy or rule limiting the amount of fluids a patient could have unless there was a specific order.

On 4/4/12 at 9:30 a.m., staff member D, unit manager, was interviewed. She stated there was no rule limiting the fluids a patient could have except for 2 cups of caffeine coffee at breakfast.

On 4/4/12 at 10:45 a.m., staff member J, Unit A, RN, was interviewed. She stated there was a rule that patients were only allowed 2 drinks per meal. When asked how the patients were made aware of the rule, she stated the staff told the patients at meal time. When asked where the rule or policy was, she stated she thought it might have been posted in the Dining Hall but otherwise, "it has always been this way".

On 4/4/12 at 11:30 a.m., staff member M, dietary staff was interviewed. She stated she was aware that there was a 2 drink limit at meal time and the psych techs monitored it in the dining hall. When asked if it was posted in the dining hall, she stated no.

On 4/4/12 at 2:00 p.m., the DON was interviewed. He stated he was unaware the staff was refusing to allow the patients fluids when requested. He further stated he was concerned the staff was "bullying" the patients and using it as a "use of power". He stated this was unacceptable.

3. On 2/9/12, patient #5 wrote on a Patient Grievance Form, "I have been one of the most respectful people and [staff member C] one of the staff has been one of the most disrespectful people and it hurts my feelings . . . "

Attached to the grievance form was a letter addressed to the patient from the facility grievance committee dated 2/2/12. The letter documented, "The results of the grievance process are as follows: . . . A member of the committee will follow up with the program manager". The letter was forwarded to the unit manager.

On 4/4/12 at 9:30 a.m., staff member D was interviewed. She stated she was unaware of the allegation from patient #5 regarding staff member C. When asked if she had received a copy of the letter, she stated she could not remember. The staff member was asked who the program manager was and she stated it was staff member F. She further stated staff member F would have taken care of the incident according to the letter.

On 4/4/12 at 10:45 a.m., patient #5 was interviewed in the presence of staff member D. He stated the staff had treated him "like a dog".

On 4/4/12 at 1:20 p.m., staff member F was interviewed. She stated she had been told recently that she was to be the program manager for Unit A but had not started. She was unaware of the incident. She further stated that the unit manager would have taken care of the incident as there was no program manager on that unit.

The allegation had not been investigated per the facility policy. The staff member continued to work on the unit with patient #5.

4. On 4/4/12 at 9:30 a.m., during an interview with the unit manager, she indicated there was an allegation against staff member B by another staff person. The staff person had indicated that staff member B had verbally abused patient #11. The unit manager stated the DON was investigating the incident and she had no knowledge of where it was in the investigation process. She further stated staff member B continued to work on A Unit with patient #11.

On 4/4/12 at 2:00 p.m., staff member A was interviewed. He stated the allegation had not been investigated to his knowledge.

On 4/4/12 at 2:15 p.m., the DON supplied a copy of an email dated 1/27/12 from an RN staff member to the unit manager, "I observed some disturbing behavior by one of the Psych Techs from A Wing yesterday 1-26-12. At lunch time for A Wing, a patient [#11] came out of the dining area into to Rotunda and went into the restroom. PT, [staff member B] came out of the dining area and held open the restroom door and shouted, ([patient #11] are you in there sticking your finger down your throat again? Yeah that's what I thought!). Then without going in to see if the patient was alright she left. There was no indication of sensitivity or for the privacy of the patient or her condition. There were several people in the Rotunda eating lunch and the exchange was plainly overheard by all sitting at the table . . . " The unit manager then forwarded the email to the DON with the following, "I addressed this with [staff member B]. She did apologized [sic] to this patient. These issues seem to surface with this staff person. Informed her the next complaint or issue would be addressed with your involvement. She is aware that such behavior could result in termination". (See A143)

The allegation had not been investigated per the facility policy. The staff member continued to work on the unit with patient #11.