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.

MOUNTAINVIEW MEDICAL CENTER 16 W MAIN ST WHITE SULPHUR SPRING, MT 59645 Jan. 20, 2021
VIOLATION: PATIENT VISITATION RIGHTS Tag No: C1054
Based on interview and record review, the facility failed to develop written policy and procedures regarding visitation rights of patients for 3 (#s 3, 4, and 6) of 9 sampled patients. This deficient practice had the potential to affect all patients receiving services by the facility. Findings include:

During an interview on 1/11/21 at 9:36 a.m., NF1 stated they were not aware of the facility's visitation procedures. They felt the facility would not allow them to visit their family member because they were not "one of the favorites" of the staff. NF1 felt the facility changed the visitation policy based on the staff preferences. NF1 said she would ask patient #3 what the visitation policy was, and patient #3 would say, "I don't know." NF1 said neither patient #3 nor them were provided the facility's visitation rights at the time of admission or when visitation policies changed.

Review of patient #3's Admission Packet, showed the patient and/or representative, dated and signed a document on 3/7/20, titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient. Patient #3's chart did not show additional notifications of changes in the facility's initiation policies.

During an interview on 1/19/21 at 11:03 a.m., patient #s 4 and 6 stated they were not aware of their patient rights of visitation.

Review of patient #4's Admission Packet showed, the patient and/or representative dated and signed a document on 1/15/21 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient. Patient #4's chart did not show additional notifications of changes in the facility's initiation policies.

Review of patient #6's Admission Packet showed, the patient and/or representative dated and signed a document on 4/17/20 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient. Patient #6's chart did not show additional notifications of changes in the facility's initiation policies.

Review of the facility's document titled, Conditions of Registration, with no date, did not address the facility's visitation rights of the patients.

During an interview on 1/20/21 at 12:45 p.m., staff member B stated the facility did not have visitation restrictions on who or when visitors were allowed to visit patients in the facility. She stated the facility would notify patients and/or their POA's by letter if there were any changes made to the facility's visitation protocols. The patients were also provided the patient rights at admission in the Condition of Registration document, which stated the facility's visitation policy. She said the facility did not have additional visitation policies which outlined the visitation rights of the patients.

Review of the facility's policy and procedure titled, Patient Bill of Rights, with a revision date of 8/5/20, showed, "r. Receive visitors at appropriate times and telephone communications, and keep and use personal clothing and possessions, unless clinically contraindicated." There were no additional policy or procedures which outlined the facility's visitation rights of the patient provided by the end of the survey.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: C1056
Based on interview and record review, the facility failed to develop written policy and procedures regarding the visitation rights of patients which included any clinical restrictions or limitations of visitations and the right of the patient to have a designated visitor for 3 (#s 3, 4, and 6) of 9 sampled patients. This deficient practice has the potential to affect all patients receiving services by the facility. Findings include:

During an interview on 1/11/21 at 9:36 a.m., NF1 stated they were not aware of the facility's visitation procedures and neither she nor patient #3 were informed of reasons for restrictions of visitations. She said patient #3 was only allowed visitors when it was convenient for the staff. She said she was not made aware of the many visitation changes which occurred while resident #3 was admitted to the facility. She was not aware if patient #3 had designated any visitors during his stay.

Review of patient #3's Admission Packet showed, the patient and/or representative dated and signed a document on 3/7/20 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which included any clinical restrictions or limitations of visitations and the right of the patient to have a designated visitor.

During an interview on 1/19/21 at 11:03 a.m., patient #s 4 and 6 stated they were not aware of their patient rights of visitation which included any clinical restrictions or limitations of visitors, or their right to designate a support person separate from their POA.

Review of patient #4's Admission Packet showed, the patient and/or representative dated and signed a document on 1/15/21 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which included any clinical restrictions or limitations of visitations and the right of the patient to have a designated visitor.

Review of patient #6's Admission Packet showed, the patient and/or representative dated and signed a document on 4/17/20 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which included any clinical restrictions or limitations of visitations and the right of the patient to have a designated visitor.

Review of the facility's document titled, Conditions of Registration, with no date, did not address the facility's visitation rights of patients to include reasons for clinical restrictions or visitation limitations which included reasons for clinical restrictions or visitation limitations and designating a visitor.

During an interview on 1/20/21 at 12:45 p.m., staff member B stated the facility did not have visitation restrictions on who or when visitors are allowed in the facility. Staff member B stated she was not aware of patients being able to designate a visitor separate from their POA. She said patients can have whomever they wish visit. She said the facility did not have any additionally developed visitation policies which outlined the visitation rights of patients to included reasons for clinical restrictions or visitation limitations and designating a visitor.

Review of the facility's policy and procedure titled, Patient Bill of Rights, with a revision date of 8/5/20, showed, "r. Receive visitors at appropriate times and telephone communications, and keep and use personal clothing and possessions, unless clinically contraindicated." There were no additional policy or procedures which outlined the facility's visitation rights to included clinical restrictions or visitation limitations and designating a support person for visitations.
VIOLATION: PATIENT VISITATION RIGHTS Tag No: C1058
Based on interview and record review, the facility failed to develop written policy and procedures regarding visitation rights of patients which did not restrict, limit, or deny visitation privileges of visitors; and ensured the policy and procedure addressed patients' visitors were provided full and equal visitation privileges consistent with patient preferences for 3 (#s 3, 4, and 6) of 9 sampled patients. This deficient practice had the potential to affect all patients receiving services from the facility. Findings include:

During an interview on 1/11/21 at 9:36 a.m., NF1 stated they were not aware of the facility's visitation procedures. They felt that the facility would not allow them to visit their family member because they were not considered "one of the favorites" of the staff. She said when she called to make an appointment to see patient #3, she wasn't allowed to see the patient or get needed signatures on a document. She said when she called one time to make an appointment to visit patient #3, she was told by staff member H that the patient had had an exacerbation of his COPD and did not want visitors. She said when she then spoke on the phone with patient #3 later in the day, the patient had said that he had become a little short of breath when walking to the bathroom earlier, but was fine, and would enjoy a visit from NF1. NF1 was still not allowed to visit the patient later.

Review of patient #3's Admission Packet showed, the patient and/or representative dated and signed a document on 3/7/20 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which did not restrict, limit, or deny visitation privileges of visitors, and ensured patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

During an interview on 1/19/21 at 11:03 a.m., patient #s 4 and 6 stated they were not aware of their patient rights of visitation which did not restrict, limit, or deny visitation privileges of visitors, and ensured patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

Review of patient #4's Admission Packet showed, the patient and/or representative dated and signed a document on 1-15-21 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which did not restrict, limit, or deny visitation privileges of visitors, and ensured patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

Review of patient #6's Admission Packet showed, the patient and/or representative, dated and signed a document on 4/17/20 titled, Conditions of Registration. The document did not address the facility's visitation rights of the patient which did not restrict, limit, or deny visitation privileges of visitors, and ensured patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

Review of the facility's document titled, Conditions of Registration, with no date, did not address the facility's visitation rights of patients to include reasons for clinical restrictions or visitation limitations which did not restrict, limit, or deny visitation privileges of visitors, and ensured the policy and procedures addressed patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

During an interview on 1/20/21 at 12:45 p.m., staff member B stated the facility did not have visitation restrictions on who or when visitors are allowed in the facility. She said the facility did not limit who can visit patients unless the patient made a specific request that they did not want to be visited or contacted by certain visitors. She said the facility did not have a policy which outlined the visitation rights of patients which did not restrict, limit, or deny visitation privileges of visitors, and ensured the policy and procedures addressed patient's visitors were provided full and equal visitation privileges consistent with patient preferences.

Review of the facility's policy and procedure titled, Patient Bill of Rights, with a revision date of 8/5/20, showed, "r. Receive visitors at appropriate times and telephone communications, and keep and use personal clothing and possessions, unless clinically contraindicated." There were no additional policy or procedures which outlined the facility's visitation rights which did not restrict, limit, or deny visitation privileges of visitors, and ensured the policy and procedures addressed patient's visitors were provided full and equal visitation privileges consistent with patient preferences.
VIOLATION: SPECIAL REQUIREMENTS FOR CAH PROVIDERS LTC Tag No: C1600
Due to the degree of the deficient practice, the facility failed to meet the Condition of Participation for Abuse and Neglect under 485.645: Special Requirements for CAH Providers of Long-Term Care Services ("Swing-Beds").

Based on interviews and record reviews, the facility failed to prevent, investigate, and report allegations of verbal abuse; and failed to develop, maintain, and implement, policy and procedures which included screening, training, prevention, identification, investigation, and protection from abuse for the prevention of patient abuse. (Refer to C 1612 for findings).
VIOLATION: FREEDOM FROM ABUSE, NEGLECT & EXPLOITATION Tag No: C1612
Based on interview and record review, the facility failed to prevent, investigate, and report allegations of verbal abuse for 1 (#3) of 9 sampled patients; and failed to develop, maintain, and implement, policy and procedures which included screening, training, prevention, identification, investigation, and protection from abuse for the prevention of patient abuse. This deficient practice has the potential to affect all patients receiving services at the facility. Findings include:

1. During an interview on 1/11/21 at 9:36 a.m., NF1 stated staff member H was rude and mean to patient #3. NF1 said one-time, patient #3 approached staff member H for something and staff member H stated, "What the hell do you want?" NF1 said patient #3 felt like he was walking on eggshells around staff member H and the way the staff member treated patient #3, hurt the patient's feelings, and made him feel like a little kid. NF1 stated she, and other family members reported the concern to a facility staff member. NF1 said she knew the facility had spoken with staff member H sometime in August or September, because things improved in relation to how staff member H treated patient #3.

During an interview on 1/19/21 at 12:03 p.m., staff member H was not able to identify the different types of abuse. Staff member H was not able to accurately describe the facility's policy and procedure on abuse prohibition, including identification, prevention, reporting, investigation, and protection. Staff member H stated he did not receive abuse prevention training by the facility upon his hire in 2016, and/or annually thereafter. He said if there were concerns of abuse he would report it in the "Yellowstone" incident reporting system.

During an interview on 1/20/21 at 12:45 p.m., staff member B stated the facility had a "no tolerance" policy regarding physical, verbal, or condescending behaviors towards patients. Staff member B stated any reports of abuse should go to staff member N for review and investigation. She said abuse training with staff has been up to each department head. She said for her department, training has been "informal for nursing staff."

During an interview on 1/20/21 at 2:30 p.m., staff member N stated she did not receive abuse training prevention, reporting or investigation, from the facility when she started in July of 2020. She said she did however attend the state abuse training in October of 2020. Staff member N stated she would take any allegation of abuse and report it to the state. Staff member N stated she was not aware of any allegations of abuse regarding patient #3.

During an interview on 1/20/21 at 4:00 p.m., staff members B and C stated any allegations of abuse would be reported to staff member N for investigation.

A review of the State Agency's Facility Reported Incidents did not show any facility reported incidents since 2015.

A review of the facility's Occurrences Summary by Category with Follow-up, dated 6/1/20 through 12/31/20, did not show any reported concerns of verbal abuse.

2. During an interview on 1/19/21 at 12:58 p.m., staff member E stated she did not recall receiving abuse prohibition training from the facility when she was hired. She was not able to identify all the types of abuse. Staff member E stated she was not sure what the facility's policy and procedure was for abuse prevention and reporting, but she would report any concerns of suspected abuse to her charge nurse, as soon as possible.

During an interview on 1/19/21 at 1:19 p.m., staff member D stated she did not receive training on abuse prohibition from the facility when she was hired. She stated she started in the kitchen before transferring to the nursing department. Staff member D was not able to identify all forms of abuse or describe the facility's policy and procedure on reporting abuse allegations.

During an interview on 1/19/21 at 2:37 p.m., staff member K and O stated they had not received training on abuse prevention by the facility when they were hired or annually thereafter. They stated they were not sure what the facility's policy and procedure was for prevention, identification, investigation, and protection, of patients from abuse. They said they would most likely report any concerns to their manager or the nurse.

During an interview on 1/19/21 at 2:45 p.m., staff member F stated she did not receive training on abuse prevention from the facility when she was hired, or annually thereafter. She said she was not sure what the facility's policy and procedure was for prevention, identification, investigation, and protection, of patients from abuse, but would let nursing now immediately if she was concerned.

During an interview on 1/20/21 at 1:11 p.m., staff member G stated she had not received abuse prevention training by the facility when she was hired and/or annually. She said she was not sure what the facility's policy and procedure was for prevention, identification, reporting, investigation, and protection, of patients from abuse, but would probably send an email to the DON, or make a report in the incident reporting system.

During an interview on 1/20/21 at 1:25 p.m., staff member I stated she had not been provided training on facility's policy and procedures for abuse prevention, identification, reporting, investigation, and protection of patients. She said if she had any concerns of abuse she would make a report in the "Yellowstone Incident Reporting" System. She said that was the way to report any concerns of abuse to the state.

Review of staff members' D, E, F, H, I, and K, personnel files, showed the staff members did not receive training from the facility on abuse prohibition.

During an interview on 1/19/21 at 2:15 p.m., staff member B stated every employee was trained differently depending on how long they had worked at the facility. She said the facility did not have mandatory training on abuse prohibition for staff at hire or annually. She said there currently was not someone in upper management who was responsible for on-boarding protocols.

During an interview on 1/20/21 at 12:45 p.m., staff member B stated the only abuse prohibition policy and procedure developed by the facility was provided during the survey.

A review of the facility's policy and procedure titled, Abuse and Neglect Reporting, with a review date of 6/11/20, showed:

- "1.0 Purpose: to define abuse and neglect and appropriate reporting.

- 2.0: Policy: The facility's is responsible for preventing abuse, neglect, and misappropriation of property. Residents and patient s must not be subjected to abuse by anyone, including, but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the individual, family members or legal guardians, friends, or other individuals.

- 3.0: Scope: This policy is applicable to all employees, medical staff, patients, visitors, students, volunteers, vendors, and contractors of [facility]. 'Facilities of properties' includes, but is not limited to, our hospital, clinics, parking lots, recreational areas, and private vehicles on [facility's] property.

- 4.0: Definitions: Neglect [neglect definition]... Abuse [abuse definition]... Injuries of unknown source [injuries of unknown source definition]... Misappropriation of resident property [misappropriation definition]... Elopements [elopement definition]...

- 5.0: Procedure: 5.1. There is a 2-hour reporting requirement to local law enforcement after the discovery of serious bodily injury from suspected abuse or neglect. 5.2. Within 24 hours, as specified in 42 C.F.R. 483.14 (c)(2) and (4), the alleged violations defined in 4.0 must be reported to the Social Services or the Director of Nursing, or the CEO. If none of those personnel are available, then report to the RN House Supervisor on duty. 5.3. The initial '24-hour report form' for the state of Montana DPHHS Certification Bureau is completed with as much information as possible at http://dphhs.mt.gov/gad/Certification."

Review of the facility provided policy and procedure for abuse prevention, failed to include screening, training, prevention, identification, investigation, and protection from abuse for the prevention of patient abuse.