WHITEFISH, MT - A state inspection at Whitefish Care and Rehabilitation revealed serious deficiencies in emergency medical response, including missing life-saving equipment during cardiac emergencies and widespread medication administration errors affecting multiple residents.
Emergency Equipment Failures During Cardiac Events
The most serious violations centered on inadequate emergency response capabilities when residents experienced cardiac emergencies. During multiple cardiac events, staff discovered critical gaps in their crash cart supplies and accessibility.
Missing Life-Saving Equipment: When residents required cardiopulmonary resuscitation, staff found that crash carts lacked essential respiratory equipment. One staff member reported: "When I arrived in resident #1's room there was not an Ambu bag on the crash cart, I had to leave the code to go and find one." The staff member had to search multiple areas across the building to locate the necessary equipment.
Accessibility Problems: The primary crash cart was wedged between a treatment cart and wall, covered by a tarp, and not easily accessible. A secondary cart in a utility room was blocked by intravenous poles and wheelchairs, making it unusable during emergencies.
Impact on Patient Care: The equipment failures directly affected emergency response times. As one staff member stated: "There was a complete delay in care from us. If we would have had the needed supplies available, it may have helped save resident #1."
Medication Administration Errors
Inspectors documented systematic failures in medication safety protocols affecting three residents receiving blood pressure medications. Staff repeatedly administered medications outside of physician-ordered safety parameters, potentially putting residents at risk for dangerous blood pressure fluctuations.
Parameter Violations: For one resident, a blood pressure medication was given 20 times when readings exceeded the "hold" parameters specified by the physician. Another resident received medication 13 times outside the ordered parameters. In a third case, staff administered a blood pressure medication 15 times without checking vital signs beforehand, despite physician orders requiring pre-administration monitoring.
Clinical Significance: Blood pressure medications require careful monitoring because incorrect administration can cause dangerous drops or spikes in blood pressure. Midodrine, one of the medications involved, is specifically used to treat low blood pressure, and giving it when blood pressure is already elevated can cause hypertensive crisis. Beta-blockers like Atenolol can cause dangerously low heart rates or blood pressure if given when vital signs are already compromised.
Staff Knowledge Gaps: While facility staff understood the requirement to check vital signs before administering medications with parameters, the practice was not consistently followed. One nurse stated: "You never give a medication with parameters if the vital signs are not recent."
Infection Control Deficiencies
The facility demonstrated significant lapses in basic infection prevention practices. Staff were observed failing to perform hand hygiene when moving between residents, handling meal trays, and administering medications.
Hand Hygiene Failures: Inspectors observed multiple instances where staff touched contaminated surfaces, handled food trays, and entered resident rooms without proper hand sanitation. One staff member administered medications after touching computer equipment and other surfaces without cleaning hands.
Enhanced Barrier Precaution Violations: A resident requiring enhanced isolation precautions due to medical devices received care without proper protective measures. Staff entered the room without using required personal protective equipment, despite the presence of a catheter and feeding tube that increase infection risk.
Training Gaps: Multiple staff members reported they had not received recent infection control training. The facility's Infection Preventionist position had been vacant since November 2024, leaving no dedicated oversight of infection prevention protocols.
Facility Assessment and Training Deficiencies
The inspection revealed that the facility had failed to update its comprehensive assessment when implementing new services, specifically a pulmonary program that had been operating for approximately one year.
Inadequate Planning: The facility assessment did not address staffing changes, equipment needs, or staff training requirements related to the respiratory therapy program. This gap in planning likely contributed to the emergency equipment shortages that affected patient care during cardiac events.
Staff Training Inadequacies: Multiple staff members reported they had not received proper training on emergency equipment locations, supply ordering procedures, or CPR certification. Some staff had worked at the facility for years without receiving CPR training, despite the critical nature of this skill in healthcare settings.
Additional Issues Identified
The inspection documented several other concerning practices including inadequate documentation of crash cart maintenance, unclear supply ordering procedures, and inconsistent knowledge among staff about emergency response protocols. The facility's policies existed but were not effectively implemented or consistently followed across departments.
The violations represent systemic failures in patient safety protocols that could affect any resident requiring emergency care or medication management. Industry standards require nursing homes to maintain readily accessible emergency equipment, follow precise medication administration protocols, and ensure all staff receive comprehensive training on safety procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Whitefish Care and Rehabilitation from 2025-01-23 including all violations, facility responses, and corrective action plans.
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