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.

WYOMING BEHAVIORAL INSTITUTE 2521 EAST 15TH STREET CASPER, WY 82609 April 6, 2017
VIOLATION: PATIENT RIGHTS: ADMISSION STATUS NOTIFICATION Tag No: A0133
Based on medical record review, staff interview, and review of information provided to patients, the facility failed to ensure the patient had the right to have a family member and his/her own physician promptly notified of admission for 15 of 15 sample patients (#3 through #17). The findings were:

1. Review of the medical records for patients #3 through #17 revealed no documentation that the patient was asked upon admission if they wanted to have a family member and their own physician notified of their admission.

2. Review of patient rights information and the patient handbook provided to patients, revealed there was no information provided to the patients that informed them of their right to have their family and physician notified of their admission.

3. During interviews on 4/6/17 at 9:58 AM, 10:06 AM, and 10:34 AM the DON confirmed that patients were not asked about notifying family and their physician of admission. She stated family contact information was obtained during the psychosocial evaluation, but that could be completed up until 72 hours after admission. She further confirmed that the medical records lacked documentation that patients were asked if they wanted family and their physician notified of their admission.
VIOLATION: MEDICAL STAFF BYLAWS Tag No: A0353
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview, and review of diabetic standing orders and medical staff by-laws rules, the facility failed to ensure staff followed the medical staff rules for 1 of 15 sample patients (#7). The findings were:

Review of the medical record showed patient #7 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II (DM II). Review of the 3/19/17 admission history and physical showed the patient was taking Glyxambi (for glycemic control and combines empaglifozin and linagliptin) and Metformin (antidiabetic agent) to control DM II. Review of the admission medication orders revealed the patient's Glyxambi was not continued upon admission. The following concerns were identified:
a. Review of the medical record showed no documented rationale as to why the patient's Glyxambi was discontinued. Further review also revealed there were no orders for monitoring the patient's blood glucose levels to monitor the effects of discontinuing Glyxambi. Review of the facility's "Diabetic Standing Orders" revealed the patient did not have those orders in his/her medical record. Further review showed the patient had a blood glucose of 252 mg/dl (milligrams per deciliter) upon admission. However, the review showed no documentation of additional blood glucose monitoring for the patient. The patient was admitted on [DATE] at 7:20 AM and discharged on [DATE] at 12:10 PM (76 hours and 50 minutes).
b. Review of the medical staff by-laws rules revealed the following requirement, "B. The Attending Physician covering shall either directly or in conjunction with a Nurse Practitioner or Physician Assistant:...10. Conduct Medication Management and order medications by specifying the medication, dosage, frequency and route of administration, and enumerate parameters and target symptoms for PRN [when necessary] medication usage, stating in progress notes appropriate rationale for initiation or significant change of medication."
c. Interview with physician assistant #1 on 4/5/17 at 10:50 AM confirmed she failed to document a rationale for discontinuing the patient's Glyxambi. She further stated that her routine for patients with diabetes was to complete a 2 page "Diabetic Standing Orders" which would include orders for glucose monitoring and intervention. She was uncertain as to why she did not include these orders for patient #7.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure nursing staff responded promptly to 1 of 5 sample patients (#15) who had a change in condition. The affected patient did not receive a response to the change in condition for 18 minutes and expired (A 395). In addition the facility failed to ensure comprehensive care plans that include interventions for all assessed patient needs were developed for 1 of 15 sample patients (#7) (A 396). These failures resulted in the inability of the facility to meet the necessary requirements for Nursing Services Condition of Participation.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview and review of policies and procedures, the facility failed to ensure staff responded promptly to a change in condition for 1 of 5 sample patients (#15) who had a change in condition. The findings were:

Review of the medical record showed patient #15 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive lung disease, hypertension, and kidney injury. Review of the 3/29/17 nursing ongoing assessments showed the patient was calm, cooperative, up in the hall and dayroom, and interacting with staff and patients. Review of the 3/30/17 nursing ongoing assessment showed the patient was cooperative with staff, ate all meals, stayed in his/her room most of the day, and complained about an upset stomach that was relieved with an antacid. Review of the code blue form, dated 3/31/17, showed the patient was found unresponsive at 6:10 AM, cardiopulmonary resuscitation was started, emergency medical system was called, and the patient expired at 6:30 AM. The following concerns were identified:
a. MHW #1 was interviewed on 4/5/17 at 8:45 AM. During the interview she gave the following information: On 3/31/17 at 5:52 AM she noticed patient #15's "breathing was abnormal and shallow and [s/he] was taking small short breaths." At that time, she reported it to RN #1, and RN #1 stated she would report it to RN #2 because RN #2 was assigned this patient's care. The MHW increased the monitoring for the patient from every 15 minutes to every 5 minutes. The MHW activated the code blue system at 6:10 AM when she observed the patient was unresponsive, not breathing, and foam was around his/her mouth. The MHW did not obtain the patient's vital signs or check for responsiveness when she noted the patient's change in condition at 5:52 AM. The RNs did not assess the patient until 6:10 AM (approximately 18 minutes after the change in condition was initially reported.)
b. Interview on 4/6/17 at 9:15 AM with RN #2 revealed she was in the medication room on 3/31/17 when the MHW noted the change in patient #15's condition. She stated she was not aware of it until the code blue system was activated. She further stated if she had known about the change in condition at 5:52 AM, she would have assessed the patient immediately at that time, and checked the pulse oximetry, vital signs, lung sounds, heart sounds and level of consciousness.
c. Review of the medical record showed no record of vital signs or nursing assessment for the time when the change in condition was first identified.
d. Interview on 4/5/17 at 11:45 AM with the chief executive officer and DON revealed they did not know why RN #1 did not assess the patient as soon as the MHW reported the change in condition. Both stated there might have been a communication problem in relating the urgency of the matter; the RN might not have understood the urgency of the situation when the MHW reported the change in condition.
e. Review of the policy and procedure for "Major Medical Emergency Treatment", revised March 2014, revealed the RN on duty will assess the individual's condition and life-threatening problems requiring medical evaluation and/or treatment immediately. On 4/6/17 at 9 AM, the DON provided a revision of this policy and procedure, approved 4/5/17, titled "Major Medical Emergency Treatment/Change of Condition." Review of the revised policy and procedures revealed specific procedures for staff to follow when they identify patients as having a change in condition. This review revealed the following directions were added to the procedures: If the change is identified by a non-licensed nursing staff they immediately notify the RN and the discovering staff will immediately obtain the patient's vital signs. In addition, the RN will respond immediately to report and conduct an assessment of patient's condition.
VIOLATION: NURSING CARE PLAN Tag No: A0396
Based on medical record review and staff interview, the facility failed to ensure a nursing care plan was developed for all identified areas which required a plan of care for 1 of 15 sample patients (#7). The findings were:

Review of the medical record showed patient #7 had diagnoses which included diabetes mellitus II (DM II). The review showed the patient had a nursing care plan. The review revealed the standard nursing care plan included an area that could be chosen for DM which included the categories of insulin or non-insulin dependence and included short-term goals and interventions. However, the review showed the DM area of the nursing care plan was left blank. Interview with the DON on 4/6/17 at 9:30 AM confirmed her expectation was for staff to include DM management in the nursing care plan for patient #7.
VIOLATION: ORDERS DATED AND SIGNED Tag No: A0454
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


Based on medical record review, review of the medical staff by-laws rules, and staff interview, the facility failed to ensure 1 of 15 sample patients (#15) had orders authenticated promptly by the ordering practitioner. The findings were:

Review of the medical record showed patient #15 was admitted on [DATE] and had physician orders dated 3/23/17 and 3/26/17. Further review on 4/5/17 revealed the orders for 3/23/17 and 3/26/17 had not been signed by the physician. Review of the medical record revealed the patient was discharged from the facility on 3/31/17. Interview with the associate administrator on 4/6/17 at 10 AM revealed the physicians were reminded to sign orders if they haven't done it within 48 hours, and the reminders continue until it is done. Review of the medical staff by-laws rules revealed the practitioners were required to sign all orders within 48 hours.
VIOLATION: PHARMACEUTICAL SERVICES Tag No: A0490
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on medical record review, staff interview, and review of facility provided communication notes, the facility failed to ensure the facility met the patient's medication needs for 1 of 15 sample patients (#7). The findings were:

Review of the medical record showed patient #7 was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type II (DM II). Review of the 3/19/17 admission history and physical showed the patient was taking Glyxambi (for glycemic control and combines empaglifozin and linagliptin) and Metformin (antidiabetic agent) to control DM II. Review of the admission medication orders revealed the patient's Glyxambi was not continued upon admission. The following concerns were identified:
a. Review of the medical record revealed the patient was taking Glyxambi prior to admission. However, the review showed the facility failed to ensure the patient's Glyxambi was continued or provide a rationale as to why the medication was not ordered. The patient was admitted on [DATE] at 7:20 AM and discharged on [DATE] at 12:10 PM (76 hours and 50 minutes).
b. Review of the 3/29/17 communication notes (not a part of the medical record) revealed the following communication from the patient to the facility, "[S/he] was taking two medications for diabetes management-nursing refused to give [him/her] one of the meds because they said they needed an order. [S/he] stopped [primary physician] in the hall and reminded him that an order was needed but [s/he] never got the medication (family/friend brought med to WBI but it wasn't dispensed-was returned to him upon discharge)." Medical record review showed the medication was not documented as having been brought to the facility or returned upon discharge.
c. Interview with patient #7's primary physician on 4/5/17 at 10 AM showed he routinely turned over medical issues for patients, which included the patient's DM II, to mid-level practitioners for management. Interview with physician assistant #1 on 4/5/17 at 10:50 AM confirmed she failed to order the patient's Glyxambi when she ordered other medications. She stated the medication was not on the facility formulary, and she was not confident that the Glyxambi would be available within the anticipated 72 hour short stay for the patient.
d. Interview with the pharmacist on 4/5/17 at 2:30 PM revealed the usual turn around time to fill a medication order if the medication is not on the facility formulary is 1 to 2 days, and he does not discourage medical staff from ordering medications that are not on the formulary.
VIOLATION: FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE Tag No: A0724
Based on observation, patient and staff interview, temperature documentation review, and policy review, the facility failed to ensure a comfortable environment for patients in 13 of 43 rooms. The findings were:

Patient #10 was observed in bed in his/her room on 4/4/17 at 4:10 PM. At that time the patient stated s/he was in bed covered with blankets because the room was cold. S/he stated the only way for him/her to get warm was to get under blankets in bed. Observation on 4/4/17 at 4:50 PM revealed room #704 was uncomfortable to the two surveyors because it was too cool even with long sleeves. Interview with the assistant director of maintenance and the associate administrator on 4/5/17 at 11:30 AM confirmed that a section of patient rooms were not receiving adequate heat due to a heating system failure since 3/29/17. Those rooms were #701 through #713 (13 rooms). The assistant director of maintenance stated parts had been ordered at that time. He and the associate administrator stated that the facility had considered moving patients who were too cold. Before the temperature had dropped, the facility had opened windows during the day when it was warmer outside. The following concerns were identified:
a. During the interview with patient #10 on 4/4/17 at 4:10 PM, s/he stated the heating system malfunctioned over a week ago and they had to order a part to repair the system.
b. During the 4/5/17 interview at 11:30 AM, both staff members confirmed that the facility failed to formulate and implement a specific plan to address the cool room temperatures in a timely manner. In addition, the facility failed to interview the patients in those rooms to determine which patients would like to move to a warmer location.
c. Interview on 4/6/17 at 10:05 AM with the assistant director of maintenance revealed the facility failed to routinely take room temperatures since the heating system failure of 3/29/17. He stated a random room temperature in the affected area was 68 degrees F. However, this was not documented. He was uncertain what the temperature in any of the affected areas was for 4/6/17.
d. Review of actual outside temperatures for the area of the facility (accessed at https://www.accuweather.com) from 3/29/17 through 4/5/17 revealed the following high and low Fahrenheit temperatures:
3/29/17 - 58/26 degrees;
3/30/17 - 58/37 degrees;
3/31/17 - 42/32 degrees;
4/1/17 - 46/26 degrees;
4/2/17 - 46/32 degrees;
4/3/17 - 41/27 degrees;
4/4/17 - 42/25 degrees; and,
4/5/17 - 54/24 degrees.
e. Review of the policy last reviewed by the facility on 3/1/16 titled, "Utility System Failure Response Policy" under "The procedures will include:" was the following: ...2. In the event of a failure, patient safety is the highest priority...5. Clinical interventions are unique and are dependent upon each type of utility system failure and the clinical situation. Contingency procedures are developed and implemented within clinical policy."