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 June 20, 2012
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on deficiencies cited, the facility failed to protect and promote the rights of 4 (#s 1, 3, 4 and 5) of 7 patients admitted to the facility. Findings include:

The facility staff did not ensure the exercise of patients' rights for 2 (#s 1, 3 and 4) of 7 patients. (See A129).

The facility staff did not protect the patients from abuse and harassment for 2 (#s 4 and 5) of 2 allegations of abuse. (See A145).
VIOLATION: ORGANIZATION Tag No: A0619
Based on observation, staff interview, and record review, the facility did not ensure food was stored under safe and sanitary conditions. Findings include:

-- The following were observed in the unit snack refrigerator:
- 8 apples and 12 oranges in the bottom drawers. Two of the oranges were covered with mold.
- 2 covered containers of pudding. One without a date. One dated 6/14/12.
- 3 sandwiches. One with no date. One dated 6/12/12, and one 6/13/12.
- 2 repackaged sliced cheese. No dates.
- 11 repackaged mixed vegetables. No dates.
- the bottom food storage shelf and both drawers were cracked in places allowing them to be potentially unclean and sanitary

On 6/18/12 at 11:50 a.m., staff members D and I, Psych Techs (psychiatric technicians), were questioned about the labeling/dating of food containers and discarding of left overs in the unit snack refrigerator. They both stated they did not know who was accountable for discarding items from the refrigerator and when they were to be discarded.

On 6/18/12 at 12:30 p.m., staff member K, Dietary Manager, was interviewed. She stated the Psych Techs on the unit were responsible for cleaning out the snack refrigerator. She further stated everything in the refrigerator should be used that day or thrown away. She was not aware the snack refrigerator was not being cleaned out. When asked how the unit staff was made aware of this, the Dietary Manager stated she did not know.
VIOLATION: PATIENT RIGHTS: EXERCISE OF RIGHTS Tag No: A0129
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review and staff and patient interviews, the facility failed to ensure that patients were free to exercise their rights for 2 (#s 1 and 3) of 7 sampled patients . Findings include:

1. Patient #1 was admitted to the facility on [DATE] with diagnosis including psychosis and tension.

During an interview with patient #1 on 6/19/12 at 2:45 p.m., it was noted he was very agitated and angry. He stated he was upset because he did not get his diet pop that day. According to patient #1, he exercised at the gym every day with a staff member. He further stated he was weighed three times a day. If his weight was over 209 pounds, he was not allowed a pop. He stated he had just worked out for an hour and felt like he was doing everything he was told to do. According to the patient, everyone else that worked out got to go over and get something but he was not allowed because of his weight. He thought his weight was up because he ate a big breakfast.

On 6/19/12 at 3:15 p.m., Staff member N, Advanced Practice Nurse Practioner, stated patient #1 had a history of polydipsia and that is why he was weighed three times a day. His last labs were reviewed and were normal, and she further stated his labs bordered close to dehydration. The orders were long standing from the previous psychiatrist and she stated, "I've just gone along with it".

On 6/19/12 at 3:15 p.m., Staff member F, Registered Nurse (RN), stated the patient did not lose the diet pop if his weight was up, but did lose his pass privileges. If he did not have a pass, then he was unable to buy a pop. When asked when a patient would lose pass privileges, she stated it was when a patient broke a rule. Staff member F was unable to show a rule regarding weight gain. She did state it was the physician's order.

The Treatment and Leisure Pass Policy was reviewed on 6/20/12 and documented,
". . . Treatment and Leisure passes may be revoked or restricted by licensed nursing staff in circumstances where it may not be safe to allow the individual off the unit, or if the person is uncooperative with treatment plan or hospital rules. . . "

2. Patient#3 was admitted to the facility on [DATE] with diagnosis including anxiety, suspiciousness, and dementia.

Patient #3 was observed in her room on 6/18/12 at 11:00 a.m. during cares. She stated to staff member E, RN that she was hungry. Staff member E stated the patient must have slept through the morning snack. Staff member E then went out to the hallway and asked staff member I, Psychiatric Technician (Psych Tech), to get the patient a snack. Staff member I stated it was too close to lunch and patient #3 could wait until lunch. At 11:50 a.m., patient #3 received her lunch tray.

On 6/18/12 at 2:20 p.m., patient #3 approached the surveyor and asked if she could show her room. Once inside the room, patient #3 stated she was "starving". Staff member I was observed at 2:25 p.m. handing out snacks in the dining area. Staff member I was notified that patient #3 was hungry. Staff member I stated, "This morning she went to the bathroom after breakfast and came out and said she didn't eat breakfast. She always does this". Staff member I did not bring a snack to patient #3. Patient #3 was not notified that snacks were being served in the dining area.
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on record review, staff and patient interviews, the facility failed to ensure that patients were free from any and all forms of abuse or harassment for 2 (#s 4 and 5) of 2 allegations of abuse. 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 6/19/12 at 2:00 p.m., during an interview with patient #4, she stated she would not take baths anymore as the staff were rough with her and had dropped her in the bathtub twice. Her tailbone had been bruised. She stated she had reported to a staff member but could not remember to whom.

On 6/19/12 at 3:00 p.m., staff member C, Unit Manager, was interviewed. She stated she was unaware of the patient's allegations. She further stated she would investigate the allegation.

On 6/20/12 at 2:00 p.m., the investigation was requested by the surveyor. The Director of Nursing (DON) stated he was unaware of the allegation made by patient #4.

On 6/21/12 at 8:30 a.m., during an interview with staff member B, DON, he stated it did not appear that the Unit Manager had initiated an investigation into the allegation from patient #4. The Unit Manager had left for vacation on Tuesday. The DON stated he spoke with the patient on 6/20/12 and her "story" was consistent with what was told to the surveyor. The DON stated he reported the allegation to the Administrator and an investigation had begun.

3. During interviews with patient #1 on 6/18/12 at 11:45 a.m., and patient #4 on 6/19/12 at 2:00 p.m., the surveyor was made aware of a concern patients #1 and #4 had regarding patient #5.

On 6/20/12 at 8:30 a.m., during an interview with the DON, the surveyor asked for information on any allegations regarding patient #5. The DON stated he was unaware of any allegations but would look into it.

a. During an interview on 6/20/12 at 12:00 p.m., the DON stated he spoke with patient #5. He stated patient #5 had made an allegation against patient #8 approximately three weeks ago. Patient #5 reported to the DON that while walking outside with patient #8, he had tried to rip her shirt off and give her a Vicodin. Patient #5 had reported the incident to the charge nurse that day. The charge nurse then reported the incident to the other unit where patient #8 resided.

b. Patient #5's medical record was reviewed. On 5/28/12 at 4:55 p.m., the charge nurse wrote in the Progress Note, "Pt [patient] reports to staff that [patient #8] from A wing has offered her Vicodin while out on pass. Stated he had tried to kiss her and made inappropriate remarks. Reported to supervisor and [staff name] RN on A wing". There was no further documentation in the patient's record regarding the incident.

c. Patient #8's medical record was reviewed. On 5/28/12 at 6:35 p.m., the psych tech wrote in the Progress Notes, "While in the dining room pt called this staff over to his table to talk. Pt [patient] stated he was feeling homicidal and wanted to go to another room. (I hate all the liars and the women of the world)....."

On 5/28/12 at 6:50 p.m., the nurse wrote in patient #8's Progress Notes, "... Dr. [name] called by this RN and discussed with him that pt refused Zyprexa. Pt becoming increasingly agitated, and threatening. No new orders received for medication. Order received to keep on unit until seen by treatment team..."

On 5/28/12 at 7:00 p.m., the nurse wrote in patient #8's Progress Notes, "Received a call from B wing - a patient (patient #5) on that unit was complaining of [patient #8] attention - she was feeling uncomfortable - reports he was offering his Vicodin and asking if she had an STD [sexually transmitted disease]. Referred to treatment team in the morning".

On 5/29/12 at 4:30 p.m., a member of the treatment team wrote in patient #8's Progress Notes, ". . . It was explained there were complaints from 2 units B & E over WE [sic] regarding intimidations/feeling uncomfortable, so treatment team feels he should remain on treatment pass until discharge in 2 days. He was intimidating and then saying he is a nice and sensitive guy. . . ". The physician wrote an order for the patient to be allowed on pass.

d. The preliminary investigation by Staff member U, Social Worker, dated 6/20/12 was reviewed and documented the following:

"Per your [Administrator] request of a preliminary investigation abuse and neglect investigation was initiated following a report by [patient #5]. Preliminary investigation was initiated. On May 28, 2012 [patient #5] stated she and [patient #8] were walking on the dirt road by the pond. [Patient #5] stated that [patient #8] asked her if she was single and if she was looking for a relationship. [Patient #5] stated that she told [patient #8] that she was not looking for a relationship. [Patient #5] stated that [patient #8] pulled out two pills and told her they were Vicodin. [Patient #5] stated that [patient #8] took one of the pills and asked her if she wanted the other. [Patient #5] stated that she told [patient #8] that she could not swallow pills. [Patient #8] told her that he could crush the pill and that she could snort it. [Patient #5] stated that she told [patient #8] that she was not interested in drugs. [Patient #5] stated that [patient #8] put his [sic] on [patient #5] hips and kissed her. [Patient #5] stated that she pushed [patient #8] away with both hands and that [patient #8] grabbed the strap of her tank top. [Patient #5] stated that she pulled away and ran back to the unit. [Patient #5] stated that when she got back to the unit she told a [staff name] Psychiatric Technician about the incident. [Patient #5] stated that it was her understanding that the psychiatric technician told [staff name] RN about the incident and that [staff name] called A wing and informed the RN on that unit. [Patient #5] stated that it was her understanding that [patient #8] was placed on a yellow level and had to be escorted by staff.

e. On 6/20/12 at 2:50 a.m., staff member T, Clinical Services, was interviewed. Patient #8's medical record was reviewed. Staff member T stated it would be documented in the record if the patient was on a restricted pass and needed to be escorted by staff. There was no documentation found in the medical record indicating that patient #8 was escorted by staff on pass. Patient #8 was discharged on [DATE].
VIOLATION: FOOD AND DIETETIC SERVICES Tag No: A0618
Based on observations, staff interview, and record review, the facility failed to:
- discard expired food items, discard opened, undated, unsealed food items in the coolers, and ensure unit staff and patients were aware of food options. (See A-0619).
- ensure the dietary department was involved with QAPI. (See A-0620).
VIOLATION: DIRECTOR OF DIETARY SERVICES Tag No: A0620
Based on observation, record review, and staff interview, the facility food service manager did not ensure the unit staff were comprehensively trained and oriented to the policy and procedures of daily dietary operations, or that the dietary service was involved in the QAPI program. Findings include:

1. Unit staff training

On 6/18/12 at 11:50 a.m., staff members D and I, Psych Techs (psychiatric technicians), were questioned about the labeling/dating of food containers and discarding of left overs in the unit snack refrigerator. They both stated they did not know who was accountable for discarding items from the refrigerator and when they were to be discarded. After further questioning, the staff members stated they were not trained in the dietary policy and procedures. They were further questioned on meal service. Both staff stated that there were no other food options if a patient wanted more to eat, or did not like what was being served. Staff member D stated that, "they get what they get and we don't ever get extra or any other option".

On 6/18/12 at 12:30 p.m., staff member K, Dietary Manager, was interviewed. She stated the Psych Techs on the unit were responsible for cleaning out the snack refrigerator. She further stated everything in the refrigerator should be used that day or thrown away. She was not aware the snack refrigerator was not being cleaned out. She was further questioned on meal service. She stated the unit staff could call the kitchen if a patient was unhappy with the meal or requested more food. If a patient wanted something else, it would be provided. When asked how this information was provided to the unit staff or patients, she stated she did not know.

2. QAPI

On 6/19/12 at 9:30 a.m., staff member K, Dietary Manager was interviewed. She was getting on track to begin working with the QA committee. She further stated she had not taken anything to the QA committee for over a year. She stated she did not make the meeting in April because she was needed in her department.

On 6/19/12 at 3:15 p.m., staff member M, Quality Assurance Coordinator, was interviewed. She stated the QA committee use to meet monthly, but recently changed to quarterly. When asked if the Dietary Manager had attended all of the meetings in the past year, the QA Coordinator stated the Dietary Manager had only been to one meeting in the past year. That meeting was in April. The QA Coordinator further stated that the Dietary Manager had not brought anything to QA for review. The QA Coordinator did state that she and the Dietary Manager were going to meet after the QA meeting in April so that she could help the Dietary Manager with quality indicators. The meeting did not happen as the Dietary Manager was unable to make the meeting. The meeting was not rescheduled.
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, the facility staff failed to remove gloves and wash hands after contamination. Findings include:

On 6/18/12 at 2:00 p.m., Staff Member D, psych tech (psychiatric technician), was observed by the surveyor. Staff Member D had started emptying the trash cans into a large barrel. He was wearing gloves. Once the barrel was full, staff member D took the barrel off the unit. When the staff member returned with the empty barrel, he still had the same gloves on. He was observed using the gloved hand to open the door to the unit and to open the door to the dirty utility room. Staff member D, came out of the dirty utility room, hands still gloved and walked down the hall to the dining area. At that time, staff member D removed his gloves and put them in the dining room trash.