Rehabilitation Hospital of Montana

“NURSING SERVICES CFR(s): 482.23 The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse. This Condition is not met as evidenced by: 44769 Due to the manner and degree of the deficient practice, Rehabilitation Hospital of Montana failed to meet the Conditions of Participation for Nursing Services at 42 CFR 482.23. Based on interview, record review, and policy review, the facility failed to: - Provide the appropriate number of nursing staff for the number and the acuity of the patients within its care, resulting in patient #1 failing to receive his tube feeding for two days. (See A-392).”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 44769 Based on interview, record review, and policy review, the facility failed to provide the appropriate number of nursing staff for the number and the acuity of the patients within its care, resulting in a patient failing to receive his tube feeding for two days, for 1 (#1) of 11 sampled patients. Findings include: During an interview on 5/4/26 at 8:30 p.m., staff member B stated there weren’t enough staff on the night shift. During an interview on 5/4/26 at 9:21 p.m., staff member B stated that the unit she was currently working on did not have a dedicated CNA, and she would have to call a CNA from another unit if she needed help with a two-person task, such as toileting a two-person lift patient. During an interview on 5/5/26 at 10:06 a.m., staff member D stated, “They don’t have enough help on the NOC shift.” Staff member D stated he worked mostly the day shift, but the administrative staff would ask him to pick up a NOC shift on occasion. He stated he would come in for his day shift at 7:00 a.m., and administration would have him leave at 10:00 a.m., then come back at 7:00 p.m. to work the NOC shift. Staff member D further stated that during the night shifts he had worked, the census was 25-26 patients, and there would be two to three nurses working. Staff member D stated he had worked the two nights that the patient, who was ordered NG tube feedings, and the feedings were not done. “I felt terrible about it, it was two days the patient missed eating, I don’t think I would have made that mistake if my brain wasn’t ‘oatmeal’. I had 14 patients and 1 CNA that night.” During an interview on 5/6/26 at 3:12 p.m., staff member C stated the facility was frequently understaffed with nursing. “These patients are Med-Surg patients, the nurse-to-patient ratio for med-surg patients is 1-6 patients per nurse.” Staff member C stated that there were nights she would only have time to listen to a heartbeat and move on to the next patient. Staff member C further stated nurses were expected to obtain all the vitals and blood sugars on their respective patients, due to the lack of aides, and sometimes those patients would be on two different halls. During an interview on 5/12/26 at 11:26 a.m., NF1 stated he resigned on 5/3/26 due to low staffing, inappropriate admission of critically ill patients, and a lack of management’s willingness to help with low staffing. During an interview on 5/12/26 at 1:38 p.m., staff member E stated the staffing expectation for the NOC shift was at least eight patients per nurse. Staff member E further stated that Staff member D was “spread thin” the two nights the NG tube feeding was missed. During an interview on 5/12/26 at 3:29 p.m., staff member G stated the patients at the facility were currently considered “high acuity” and were “med-surg” patients. During an interview on 5/12/26 at 7:36 p.m., staff member F stated that weekend shifts were frequently understaffed and that when a nurse called off, they would be really understaffed. Staff member F further stated that a nurse would call off on the weekends about 35-40 percent of the time. During an interview on 5/6/26 at 10:37 a.m., staff member A stated that her standard practice related to staff scheduling was to bring in the maximum number of nurses allowed to be budgeted, and it could not go below 7.7 HPPD (Hours per Patient Day). During an interview on 5/7/26 at 8:27 a.m., staff member A stated that on 2/13/26, there were three nurses who worked a full shift and one nurse worked 8 p.m. to 10 p.m., to help with medication pass. Staff member A further stated that four nurses would have been good. The census on 2/13/26 was 26 patients. Staff member A relayed on 2/14/26, there were two nurses that worked a full shift, one nurse that worked three and a half hours, and three CNAs worked the full shift. The census on 2/14/26 was 26 patients. Staff member A further relayed “they would shoot for four nurses” for that census number. Staff member A stated the facility went through a period around February 2026 when they were short on nurses and CNAs: “We had a hard time getting travelers as well.” A review of a facility document titled “Root Cause Analysis and Action Plan Framework Template,” showed: “When did the event occur? Date 2/14/26, 2/15/26 ... Detailed Event Description Including Timeline: ...On Saturday, 2/14/26 and Sunday 2/15/26, patient [initials] did not receive tube feed as ordered. Order was: ‘125 mL/hr start @ 5 pm x 11 hours. ... 2. Were there any steps in the process that did not occur as intended? ...Nursing didn’t review order. [Tube Feeding] order wasn’t thoroughly discussed in BSSR ... 3. What human factors were relevant to the outcome? ...The night shift nurse stated he was very fatigued. ... 7. Were there any other factors that directly influenced this outcome? ...Nursing staff becomes complacent with BSSR, especially when short staffed or late admits. Just give highlights and don’t discuss in-depth because there isn’t time ... 10. How did actual staffing compare with ideal levels? ... Night shift was short-staffed, so a day shift RN was moved to cover ... 20. What barriers to communication of potential risk factors? ... Staff feeling rushed to get through BSSR, especially when short-staffed ...” [sic] The document listed seven “Action Items” under the “Action Plan,” but adjusting or increasing staffing was not listed. A review of an as-worked schedule for 10/14/25, night shift, showed two nurses and three CNAs worked the full shift. The facility census was 23 patients. One nurse had 11 patients, and another had 12. A review of an as-worked schedule for 2/13/26, night shift, showed three nurses and two CNAs worked the full shift, and one CNA worked from 6 p.m. to 9 p.m. The facility census was 26 patients. A review of an as-worked schedule for 2/14/26, night shift, showed two nurses and three CNAs worked the full shift, and one nurse worked three and a half hours. The facility census was 26 patients. A review of a facility document, titled “Staffing Guidelines, HPPD (Hours per Patient Day) 7.70.” showed that night nursing staffing levels should be: “...1 nurse and 1 CNA for 1-10 patients, 1 nurse and 1.5 CNAs for 11-12 patients, 1 nurse and 2 CNAs, for 13-15 patients, 2 nurses and 1 CNA, for 16 patients, 3 nurses and 2 CNAs for 17 to 21 patients, 3 nurses and 2.5 CNAs for 22 patients, 3 nurses and 3 CNAs for 23 patients, 3.5 nurses and 3 CNAs for 24 patients, 4 nurses and 3 CNAs for 25-26 patients, and 4 nurses and 4 CNAs for 27 patients.” A review of a facility policy titled, “Nursing Staffing,” with a revision date of 6/3/2025, showed: - “Policy: The Rehabilitation Hospital provides 24 hour care to patients who have complex rehabilitative needs. The Nursing Services Department is operational 24 hours a day, 7 days a week. Nurses typically work 12 hour shifts. The Board of Managers has the final approval of this policy... - B. Staffing and Delivery of Care: 2. There shall be adequate numbers of RNs, LVNs and other personnel to provide nursing care to all patients ... 6. The RN shall supervise and evaluate the nursing care for each patient and assigns the nursing care to other personnel in accordance with the patient’s needs and specialized qualifications and competencies of the nursing staff present. ... - C. Staffing: 1. The staffing levels for each unit are based on several critical factors: a. Patient characteristics and the number of patients for whom care is being provided, including the number of admissions, discharges and transfers. b. Acuity of patient care being provided. c. Variability of patient care across the unit. d. Scope of services provided. e. Context within which care is provided, to include architecture and geography of the environment, and availability of technology. f. Nursing staff characteristics, including staff consistency and tenure, preparation and experience, and the number and competencies of clinical and non-clinical support staff the nurse must collaborate with or supervise...” [sic] A review of the facility’s website on 5/12/26 at 6:57 a.m., under the “Why Choose Us” tab showed, “ ... Low patient-to-rehab nurse ratio goal: 5-7 patients to one rehab nurse ...” https://www.rehabhospitalofmontana.com/about-us”