Battle Mountain General Hospital

In the surveyor’s words

From the most serious findings on record at Battle Mountain General Hospital, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF868Feb 6, 2025

  Based on document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include the Infection Preventionist, Chief Nursing Officer and the Medical Director. Findings include: The facility provided a list of QAPI Committee members. The list documented the QAPI committee was comprised of the Chief Executive Officer, the Chief Nursing Officer, the Medical Director or designee, the Infection Preventionist, and two other facility staff. On 02/06/2025 at 11:03 AM, the Risk Manager verbalized the QAPI committee required at a minimum the Administrator, the Director of Nursing, Medical Director or designee, the Infection Preventionist and two other staff members. […]

• No harm, potential for more than minimal, widespreadF563Feb 9, 2021

  Based on interview and document review, the facility failed to follow the Centers for Medicare and Medicaid Services (CMS) and Centers for Disease Control (CDC) guidelines for allowing visitation. Findings include: On 02/01/21 at 2:30 PM, Certified Nursing Assistant #1 (CNA) verbalized no visitation was allowed. On 02/01/21 at 2:32 PM, CNA #2 verbalized no visitors were allowed in the facility. On 02/01/21 at 12:12 PM, the Chief Executive Officer verbalized no visitation was allowed in the facility except for compassionate care visits. Resident #13 Resident #13 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 02/03/21 at 8:38 AM, Resident #13 verbalized visitors were not allowed to come to the facility. […]

• No harm, potential for more than minimal, widespreadF658Feb 9, 2021

  Based on interview, clinical record review, and document review the facility failed to have a Standard of Practice available for the nursing staff, failed to ensure a Registered Nurse (RN) performed the duties as outlined in the State Board of Nursing Nurse Practice Act, and failed to prevent a Licensed Practical Nurse (LPN) from completing bed rail assessments on 22 of 22 residents (Resident #1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 174.) Findings include: Lack of Standard of Practice On [DATE] at 9:17 AM, the Licensed Practical Nurse (LPN) verbalized not knowing what Standard of Practice was used in the facility. […]

• No harm, potential for more than minimal, widespreadF700Feb 9, 2021

  Based on interview, record review, and document review, the facility failed to ensure residents did not have bed rails installed, in use, or physician ordered prior to attempting of appropriate alternatives and completed assessment for 22 of 22 residents (Resident #1, 2, 3, 4, 5, 7, 8, 9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, and 174.) Findings include: On 02/03/21 at 4:00 PM, the following residents' beds were observed with bed rails in the up position: Resident #1 Resident #1 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #1's bed had four bed rails in the up position. Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF727Feb 9, 2021

  Based on interview and document review the facility failed to have a Registered Nurse (RN) on duty 8 hours a day, 7 days a week and failed to have a full-time Director of Nursing (DON). Findings include: On 02/02/21 at 10:10 AM, the Human Resources Director verbalized the following: - The Long-Term Care Facility (LTCF) did not have a DON position and utilized the Chief Nursing Officer (CNO) to cover as the DON, - The CNO performed administrative duties for the hospital, the emergency room , and the LTCF, - The Human Resource Director did not know if there were any staffing waivers in effect, - The RN's working in the hospital's emergency room were utilized as a resource for the LTCF, - The facility did not have a job description for the DON or Charge Nurse positions, - The facility… […]