Citations in Montana
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Montana.
Statistics for Montana (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Montana
A quadriplegic resident was transferred to another facility without being provided with a wheelchair, despite reliance on it for mobility, and arrived at the receiving facility without one. Additionally, the facility did not document the discharge in the medical record, omitting key information about the transfer and the resident's care.
A resident with a below-the-knee amputation had their stump secured to a wheelchair footrest using a compression wrap that could not be removed independently. Staff used the wrap without a physician's order, assessment, or documentation, and there was no monitoring or evaluation of the restraint or the resident's skin. Facility policy requiring assessment and authorization for restraints was not followed.
A resident with a wound and intermittent confusion was admitted and required varying levels of assistance with activities of daily living, but no baseline care plan was completed within 48 hours as required. Staff confirmed the care plan was still blank at the time of review, despite facility policy mandating timely completion to address immediate care needs.
A resident who was missing teeth and relied on dentures did not have a care plan that accurately reflected their dental status or specific oral care needs. Staff provided inconsistent oral and denture care, and family members reported having to clean the resident's dentures themselves due to staff neglect. The facility's care plan lacked essential details, and documentation of oral care was insufficient.
A resident with a left below-knee amputation refused to wear a prescribed brace, leading staff to use a compression wrap to secure the stump to the wheelchair leg rest. The care plan was not updated to reflect the resident's refusal, the use of the compression wrap as a restraint, or related risks, despite facility policy requiring such revisions.
A resident with diabetes and neuropathy developed a foot ulcer that was not properly identified, documented, or treated by facility staff despite physician identification and a history of toe wounds. Weekly skin assessments failed to note the wound, prescribed treatments were not administered as ordered, and communication with wound care providers was inadequate. Delays and omissions in care led to the wound worsening, ultimately resulting in hospitalization and amputation of the resident's right great toe.
Nursing staff did not identify, assess, or document a diabetic foot ulcer for a resident, despite a physician's note and ongoing risk factors. Weekly skin checks failed to detect the ulcer, and prescribed wound care was not administered. Staff interviews revealed inconsistent assessment practices and a lack of formal wound care training. The resident was ultimately hospitalized and required amputation of the great toe due to lack of early identification and treatment.
A resident with diabetes and neuropathy developed new foot wounds, but the facility did not update the care plan to reflect the resident's history of foot sores or provide preventative interventions for diabetic foot ulcers. The care plan was not revised to include the diagnosis or specific interventions for the ulcer until months after the issue was identified, leaving staff without clear guidance for care.
A facility licensed for 160 beds did not employ a full-time social worker who met regulatory requirements, as the staff member in the social services director role held a psychology degree instead of a social work degree and lacked the required supervised healthcare experience. Despite the facility's census being below 120, regulations require a qualified social worker based on licensed bed count, not census. This deficiency was linked to concerns about meeting residents' mood, behavioral, and psychosocial needs.
Leadership failed to identify and address a nurse's ongoing cognitive and performance issues, resulting in over 50 medication errors and missed care tasks for multiple residents. Despite repeated reports from staff about the nurse's confusion, slurred speech, and unresponsiveness, supervisors did not document or investigate these concerns, allowing neglect of care to continue for several months.
Failure to Provide Wheelchair and Proper Discharge Documentation
Penalty
Summary
A quadriplegic resident, who required a wheelchair for primary mobility due to spastic quadriplegic cerebral palsy, was discharged and transferred to an Adult Services Residential Program facility in Pennsylvania without being provided with a wheelchair. Interviews with staff revealed that although there was discussion about sending a manual wheelchair with the resident, there was no documentation confirming that a wheelchair was actually sent. The receiving facility reported that the resident arrived without any wheelchair, manual or electric, which was his main mode of locomotion. Additionally, the facility failed to document the transfer and discharge of the resident in the medical record. There was no discharge progress note on the day of discharge, and essential information such as a summary of the resident's stay, education on medications and treatments, a list of belongings, details of who picked up the resident, and the reason for discharge were missing. All discharge documentation was handled through email and TEAMS meetings rather than being properly recorded in the medical record as per facility policy.
Failure to Ensure Resident's Right to Be Free from Physical Restraints
Penalty
Summary
A resident with a left below-the-knee amputation was observed with their stump secured to a wheelchair footrest using a tan compression wrap, which the resident was unable to remove independently. Staff interviews revealed that the compression wrap had been used for some time to keep the stump in place because the resident would not wear their prescribed brace. Multiple staff members acknowledged that there was no physician's order for the use of the compression wrap as a restraint, and no assessment or documentation was completed regarding its use. Staff also indicated a lack of awareness about the need for documentation or assessment, and some staff were under the impression that securing the stump in this manner was permissible. Record reviews confirmed the absence of a physician's order, assessment, or documentation related to the use of the compression wrap as a restraint. There was no evidence of monitoring, release, or skin assessment for the area where the wrap was applied. Additionally, therapy evaluations did not address the use of the compression wrap for stump positioning. The facility's own policy prohibits the use of physical restraints without proper assessment, documentation, and physician authorization, none of which were present in this case.
Failure to Complete Baseline Care Plan Within 48 Hours of Admission
Penalty
Summary
A deficiency occurred when the facility failed to complete a baseline care plan within the required 48-hour timeframe for a newly admitted resident. The resident, who had a wound and experienced forgetfulness and confusion, was observed at the nursing station wearing soiled clothing and reported needing assistance with dressing and hygiene. Documentation showed that the resident's needs for activities of daily living varied, requiring different levels of assistance, but no baseline care plan was in place to address these needs within the mandated period. Interviews with staff confirmed that a baseline care plan had not been completed for the resident, and at the time of the survey, the care plan in the electronic medical record was still blank. The facility's policy required that a baseline care plan be developed and implemented within 48 hours of admission, including essential healthcare information to properly care for the resident. The lack of a timely baseline care plan had the potential to affect all new admissions.
Failure to Develop and Implement Comprehensive Oral Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered, comprehensive care plan that adequately assessed and addressed the dental status and oral care needs of a resident. Observations revealed that the resident was lacking teeth and relied on dentures, which had been lost by the facility and replaced by an old pair provided by family. Interviews with staff indicated inconsistent practices regarding oral and denture care, with some staff believing that if dentures were already in place, oral care was unnecessary. The resident's care plan did not specify whether the resident had no teeth or dentures, nor did it outline the specific type of oral care required. Further interviews with family members revealed that the facility had not replaced the lost dentures as expected, and that family members had to clean the resident's dentures themselves due to staff neglect. The facility's policy required comprehensive, person-centered care plans that included resident-specific interventions, but the care plan for this resident lacked essential details about dental status and oral care needs. Documentation and communication regarding refusals of care and the resident's oral health status were also found to be insufficient.
Failure to Revise Care Plan After Resident Refusal and Use of Restraint
Penalty
Summary
The facility failed to revise a resident's care plan after the resident refused to wear a prescribed brace and staff began using a compression wrap to secure the resident's left below-knee amputation stump to the wheelchair leg rest. Observations showed the resident was unable to remove the compression wrap and was seen pulling at it. Staff interviews revealed that the use of the compression wrap was not documented in the care plan, and refusals of the brace were not consistently recorded or reported. Staff also indicated that the use of the compression wrap had been ongoing and was not based on a documented care plan intervention. Review of the resident's comprehensive care plan showed no updates or interventions related to the use of the compression wrap as a restraint or the resident's refusal to wear the brace. The care plan only referenced the brace and monitoring under it, with no mention of the alternative intervention or associated risks. Facility policies required the care plan to be reviewed and revised by the interdisciplinary team and updated to reflect any restraint use, but these steps were not followed for this resident.
Failure to Identify, Document, and Treat Diabetic Foot Ulcer Resulting in Amputation
Penalty
Summary
A facility failed to properly identify, assess, document, and treat a diabetic foot ulcer for a resident with a history of diabetes, neuropathy, and previous toe wounds. The physician initially identified a wound on the resident's right great toe in June, but the facility did not document or add this wound to the resident's diagnoses or care plan until several months later. Despite the resident's high risk for skin breakdown and a documented history of toe wounds, the care plan and interventions were not updated in a timely manner to address the new ulcer. Weekly skin assessments conducted by nursing staff repeatedly failed to identify or adequately document the right great toe wound, even after it was noted by the physician. There were inconsistencies and omissions in the administration of prescribed treatments, such as Mupirocin ointment, which was not administered as ordered in June and July. When the resident was sent to a wound care clinic, the facility failed to provide necessary documentation or communicate the specific concerns, resulting in the clinic being unaware of the wound and unable to provide targeted care. Additionally, there were delays in implementing wound care orders, with a nine-day gap between the order for Thera honey and PolyMem dressings and the start of treatment. Throughout the course of the resident's care, there was a lack of effective communication and follow-through among facility staff regarding the resident's wound status and treatment needs. Progress notes, skin assessments, and notifications to providers were incomplete or missing, and the resident's worsening condition was not promptly addressed. The failure to identify, monitor, and treat the diabetic ulcer led to the deterioration of the wound, resulting in hospitalization and amputation of the resident's right great toe.
Failure to Identify and Manage Diabetic Foot Ulcer Leads to Amputation
Penalty
Summary
Facility staff failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to identify, assess, document, and monitor a diabetic ulcer for one resident. Despite a physician's note documenting a diabetic ulcer on the resident's right great toe, weekly head-to-toe skin checks performed by facility staff throughout July failed to identify any skin issues. The first documentation of a skin alteration on the right great toe did not occur until early August, well after the physician's initial identification. Additionally, the medication administration record for July and August did not show evidence that staff administered the prescribed Mupirocin ointment as ordered by the physician. Interviews with staff revealed inconsistent practices and a lack of formal wound care training among nursing staff. One staff member admitted that skin issues might be missed depending on the thoroughness of the assessment and noted that formal wound care training was lacking, aside from wound vac training. Documentation and follow-up with the physician were also insufficient, as there was no evidence of ongoing monitoring or communication regarding the resident's diabetic foot ulcer after its initial identification. Ultimately, the resident required hospitalization and amputation of the right great toe after a wound care appointment, due to the facility's failure to provide necessary services for early identification, ongoing treatment, and preventative interventions.
Failure to Develop and Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address a resident's diabetic foot ulcer and history of foot wounds. Documentation showed that the resident, who had a history of diabetes, neuropathy, and previous toe wounds, presented with new open and scabbed areas on the right toes. Despite these ongoing and new issues, the care plan did not reflect the resident's history of foot sores or provide specific preventative interventions for diabetic foot ulcers. The care plan was not updated to include the diagnosis of a diabetic ulcer until several months after the condition was identified, and interventions specific to the ulcer were only added after a significant delay. Interviews with staff revealed that nurses were responsible for updating care plans when new issues were identified, and that preventative measures should be included in the care plan. However, the care plan for this resident lacked documentation of the resident's history of foot problems and did not guide staff on preventative care for diabetic foot ulcers. Staff also indicated that changes to care plans were communicated during shift reports, but the care plan still failed to include necessary information to direct care for the resident's ongoing and current foot issues.
Failure to Employ Qualified Full-Time Social Worker in Facility Licensed for Over 120 Beds
Penalty
Summary
The facility failed to hire and employ a full-time social worker who met the regulatory requirements for a facility licensed for more than 120 beds. Specifically, the facility was licensed for 160 beds, but the individual in the social services director position held a bachelor's degree in psychology rather than in social work, and did not have the required one year of supervised experience in a healthcare setting. Another staff member working in a social services role also did not have a degree. The facility's job description for the social worker position required a bachelor's degree in social work and a state social work license, but the current staff member did not meet these qualifications. Interviews with facility staff revealed that the facility's census had never reached 120 residents, and staff believed that having two staff members in social services roles was sufficient to meet regulatory requirements. However, regulatory review confirmed that the requirement for a qualified full-time social worker applies to facilities with more than 120 beds, regardless of current census. The report also referenced related concerns with residents not receiving necessary care and services for mood, behavior, and psychosocial needs, as outlined in F656 and F740.
Failure to Address Staff Member's Declining Performance Led to Neglect of Resident Care
Penalty
Summary
Leadership staff failed to ensure residents were free from neglect by not identifying, addressing, or correcting concerns related to a staff member's performance over several months. Staff member R was responsible for more than 50 medication errors affecting 11 residents, including failures to administer medications, complete glucose checks, and perform skin checks as required by physician orders. Despite these errors, the facility reported that no harm was found for the residents, but the required care was not provided as ordered. Multiple staff members observed and reported significant changes in staff member R's behavior and cognitive status, such as confusion, slurred speech, slowed gait, weight loss, and periods of unresponsiveness. These concerns were communicated to supervisory staff, but were not documented, investigated, or escalated appropriately. Staff member D, after receiving reports, only briefly observed staff member R and did not take further action unless she personally identified an issue. Other staff, including staff members E and L, also noted missed medications and cognitive changes but did not report or document these concerns to higher management. The lack of an effective system to track, investigate, and respond to repeated reports of staff member R's declining performance and health resulted in ongoing neglect of care for multiple residents. The facility leadership did not ensure that concerns about staff member R's ability to safely perform her duties were properly managed, leading to a prolonged period during which residents did not consistently receive necessary medications, treatments, or monitoring as ordered.
Some of the Latest Corrective Actions taken by Facilities in Montana
Facility corrective actions were not detailed in the provided information for these citations.
Failure to Prevent and Document Progression of Stage 4 Pressure Ulcer
Penalty
Summary
The facility failed to prevent, assess, and document the progression of a Stage 4 pressure ulcer for a resident. The resident was readmitted to the facility without a sacral pressure ulcer, but by September 2023, a pressure ulcer of the sacral region was diagnosed. The wound care progress note from November 2023 indicated that the pressure ulcer had been present for nine weeks and was classified as Stage IV. There were no weekly skin or wound assessments until late September 2023, and no assessments were conducted in October or November 2023. Consistent weekly assessments only began after the initiation of a Wound Care Performance Improvement Plan (PIP) in December 2023. Interviews with staff revealed that new management identified wound care as a significant concern and initiated a PIP to address the issue. Contributing factors to the skin concerns included a lack of pressure-reducing mattresses and pads, poor layering of linen and plastic pads under residents, and inadequate wound documentation. The facility's QAPI team implemented immediate interventions, including the use of pressure reduction mattresses and pads, changing to cloth bedding protectors, weekly graphing of wounds, and a consistent wound care protocol. These actions were part of a broader effort to improve wound care processes and reduce the incidence of pressure ulcers among residents.
Removal Plan
- Pressure reduction mattresses and pads
- Change from plastic to cloth bedding protectors for better air flow to skin
- Graphing of wounds
- Wound care protocol for consistency of wound care/nutritional interventions
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