HospitalInspections.org

Based on a review of facility documentation, and an interview with staff, the facility's organizational structure failed to have a governing body or individual to implement policies to provide quality health care in a safe environment.

Findings: Review of the facility's fire drill documentation, on the morning of 7/30/25, revealed the last fire drill with "Participating Drill Attendees Sign-In Sheet," was conducted 2-25-25 and did not provide documentation as required by the facility policy

On the afternoon of 7/30/25, review of the facility "Fire Drill Procedures/Fire Drill Record Keeping, effective 5/2025 partly stated:
POLICY:
To establish a standard procedure for conducting Fire Drills. This policy will cover the procedure for conducting the drill; include a Fire Drill Evaluation Form, and the drill planning . To maximize staff development and the training effectiveness of the drill exercise, it is important to develop a good procedure and a competent Drill Observer Team

PROCEDURE:
1-Establish a monthly schedule for conducting drills. Drill will be performed in the morning and late evening hours to ensure that both two- 12 hour shifts are in compliance with established requirements.
2. The Safety committee is to establish a group of individuals that will form the drill monitor team. Training if necessary will be provided to the team.
3. The Safety committee will adopt a standard format upon which to report activities during the drill. This will come to be known as the "Fire Drill Evaluation Form".
4. At the conclusion of each drill the team should meet to discuss the drill and complete their reports.
5. A copy of these reports will be kept on file in the Safety Office with the original being submitted to the safety committee.

In interview on the morning of 7/31/25, with the Safety Director , Staff #5 , it was confirmed the facility policy was not being followed .

Based on document review and interview, the facility failed to supervise and evaluate the nursing care for patient #10 when physician orders for wound care was not followed upon admit to swing bed unit.

Findings:
Review of patient medical record 7/29/25 revealed the following:
Nursing order on 7/3/25 entered by admitting nurse
"1431 - place on swing bed
- DX: wound care to right tibia/wound vac;IV antibiotics
- physical therapy eval for wound care to right tibia
A review of the initial nursing skin assessment 7/3/25 identified no data describing the wound.

Initial physical assessment 7/3/25 at 1346 by admitting nurse completed. Documentation revealed Staff #13 from Physical therapy (PT) removed dressing from RLE (right lower extremity) and measured wound, applied clean dressing, physician notified of patient arrival. No other documentation provided.
Nurse Progress note 7/4/25 at 0728: Dressing to RLE with swelling & discoloration to outside of dressing.
No documentation that physical therapy had performed wound care evaluation and applied wound vac per physician admitting order 7/3/25.

In an interview with staff # 7 it was stated patient #10 did not receive wound care evaluation with wound vac until 7/5/25. There was no documentation that the physician had been notified for further orders. In an interview 7/31/25 with the attending physician/Medical Director, staff #15 confirmed the above findings.

After further review Staff #1 &10 confirmed that facility staff did not follow policy and physician orders.

Based on observation, policy review and interviews the hospital's infection prevention and control program failed to maintain a clean and sanitary environment to avoid sources and transmission of infection, when observation revealed areas within the facility that were not adequately cleaned and/or could not be adequately cleaned (cardboard boxes, missing tiles, black substance, rust, etc.). These findings had the likelihood to cause harm by increasing the risk of infection to all patients and staff at the hospital.

Findings were:

In an article published by Spectrum Health in July 2014 it was stated, "The heavier corrugated cardboard shipping boxes might harbor vermin or insects and spread the pests to areas where the boxes are stored after delivery. Corrugated cardboard boxes are not appropriate as storage units in medical or clean supply rooms. These boxes are not appropriate because they are an excellent harbor for insects and pests."

A review of the hospital's "Infection Control Program" policy #18198987 dated 06/2025 revealed the following:
"Functions: the committee will help ensure this organization develops, implements, and maintains an active organization-wide program for the prevention, control, and investigation of infections/communicable diseases through the following activities. These activities exist to reduce the risks of endemic/epidemic infections in patients, visitors, and HCWs (health care workers) and to optimize available resources. The activities include, in part:

-Maintenance of a sanitary hospital environment ...
-Review the preventive, surveillance, and control procedures relating to the inanimate hospital environment. This includes sterilization and disinfection procedures in surgery, housekeeping, laundry, maintenance, dietary, and waste management ..."
During a tour of the hospital on 07/30/25 at 11:15 a.m., accompanied by Chief Nursing Officer (CNO), Staff #1, and other administrative staff revealed:

Pharmacy
-There were cardboard shipping boxes, containing intravenous (IV) fluids, observed being stored on the counter in the pharmacy sterile supply room. Corrugated boxes are not appropriate because they are an excellent harbor for insects and pests.
-There was an accumulation of dust and debris on the cabinet shelf under the sink.

Radiology
-There were cardboard shipping boxes, observed being stored on the counter in the supply room. Corrugated boxes cannot be cleaned and may harbor insects and pests.

Cardiopulmonary
-There was an accumulation of dust and debris on the cabinet shelf under the sink in the storage room.

Laboratory
-There was an accumulation of dust and debris on the cabinet shelf under the sink and the area was being used for storage.

Labor and Delivery Wing
-There was a broken and missing piece of tile in the hallway. This prevents thorough disinfection, cleaning, and sealing of the floor surface.
-There was chipped and missing wood on the patient door closest to the nursing station. Porous surfaces cannot be sanitized.

Post-partum Hallway Office Space
-There was an unknown dried brown substance in the light fixture.
-There was a cracked ceiling tile. This could allow for dust and insects to enter the room.

Staff #1 and other administrative staff acknowledged the infection control issues found during the tour of the hospital.


An observation tour of the kitchen was conducted on 07/30/25 at 2:30 p.m. with Dietary Supervisor, Staff #16. The following infection control concerns were observed.
-There was a black growth on the wall above the fan unit in the walk-in refrigerator. Indicating inadequate cleaning of the interior refrigerator walls.
-There was a layer of ice build-up in the upper left corner and rust on the door screws of the interior double-pane insulated glass window of the walk-in freezer, a puddle of rust colored liquid had accumulated on the bottom right of the windowsill and was seen dripping down the exterior freezer wall. Rusted areas cannot be sanitized.

In an interview with Dietary Staff #16, on the afternoon of 07/30/25, stated the following:
-" ...cleaning duty assignments are posted monthly, each team member rotated areas weekly, both the refrigerator and freezer are part of the cleaning assignment." Monthly cleaning assignments were visibly posted on exterior window of Dietary Staff#16 office and did include walk-in refrigerator interior walls and walk-in freezer.
-" ...this freezer door has been sealed before but did not stop the problem." Clear sealant was visible around the circumference of the exterior freezer window.

Dietary Staff #16 acknowledged the infection control concerns found during the observation tour. These infection control issues presented a safety risk to patients and staff.

Based on record review and interview, the facility failed to ensure the Emergency Preparedness Program (EPP) provided the training and documentation to all new, existing and individuals providing services under arrangement, and volunteers, consistent with their expected roles
Findings:
Review of the EPP policy, procedures and training documentation revealed failure to conduct and maintain documentation of staff training at least annually. This could delay evacuation and response during an emergency, which could cause injuries.

In an interview 7/30/25 with Staff #2 and Staff #5, the above findings were confirmed.

Based on interview and record review, the facility failed to have a QAPI (Quality Assurance and Performance Improvement) that was ongoing and comprehensive.

Findings :
A review of QAPI (Quality and Performance Improvement) meeting minutes of December 2024 thru June 2025 revealed the following:

A review of the hospital policy titled; "Quality Assurance/Performance Improvement Plan" dated 01/2025 revealed the following:
POLICY:A performance Improvement Program will be in effect to insure that quality care is given on an individual basis to meet the needs of the patients, employees, board of directors, volunteers and the wider community.

The quality improvement process and system is coordinated by the QA/PI department though, all staff and Board Members participate in the quality improvement practice.
PROCESS:
A. Each department will establish a working Performance Improvement program utilizing ACI and will focus on areas that are pertinent to the department and will be consistent with the goals and objectives of the hospital.
B. Problems will be identified by:Assessing key functions of patient care, and or any hospital policy/procedure.
C. Priority will be determined for assessment and/or resolution
D. Appropriate corrective action for each deficiency will be implemented through inservice/education, policy revision
and re-evaluation.
E. Re-evaluation of action's effectiveness is performed to ensure the desired results were achieved. Key questions to
ask to evaluate an activity include:
1. Did the action achieve the desired result or outcome?
2. Is there any further action to be taken in this area?
3. Once the PI Action Plan has been resolved the department manager will report the resolution at the quarterly QA/PI meeting.
F. Quarterly each department will review their plan and revise as needed.

An interview with Staff # 6 (Director of Quality) on 07/29/25 acknowledged that all departments of the hospital were reporting, but there was no plan to evaluate if the departments were meeting objective measures to evaluate their processes, functions, and services to provide safe patient care.

Based on a review of facility documents and interviews, the,hospital's governing body failed to approve and be responsible for the effective operation of the grievance process, review and resolve grievance .

Findings:
Facility policy titled"Patient Grievance/Complaint Policy", effective 10/2024 partly stated:
To meet the patient(s) reasonable expectations of care and services, the PCMH Health System attempts to address grievances/complaints in a timely and consistent manner. As part of the notification for patient rights, the facility will provide the patient with contact information for the appropriate state licensing agency. This information is provided to the patient during the admission process in written form through the Patient Handbook. The goal is to ensure ongoing quality improvement for patients and visitors through a process where the comments(negative or positive) provided by the patient and/or visitors are documented and the appropriate action is taken, and outcomes monitored. Effective March 1st, 2016 this process is managed through Action Cue and coordinated by the Risk Management and Performance Improvement process.

Procedure
A patient or the patient's representative, or a visitor may file a grievance/complaint at any given time. If the issue cannot be resolved immediately, an Event Report should be initiated and documented on Action Cue by the staff member who became aware of the grievance/complaint. The Event Report should then be electronically forwarded to the appropriate department manager for investigation and review. Events should be documented no later than 24 hours from the date of knowledge of the event, and if on a weekend or holiday, on the following workday. Information reported and documented should include clear and objective facts. The patient or the patient's representative will be notified by phone of the process allowing 7 days for review and investigation, not including weekends. If the event cannot be resolved or the investigation cannot be completed, the patient or patient representative will be notified in writing of action to be taken, if any, within 30 days from the date the event was reported. The final written notice will include the name of the facility, the designated contact for the facility, the steps taken to investigate, the result(s) of the investigation, and the date of completion.
The Risk Management Coordinator and the Hospital Administrator will monitor all events and determine what action, if any,will be taken regarding the event. The facility endeavors to resolve issues fairly and impartially, which may include refusal of any staff member who is the subject or whose department is the subject of the grievance/complaint from actively participating in the final action, but not necessarily the discussion of the events. The governing body of the hospital (Board of Managers) reserves the right to conduct its own review of any patient grievance/complaint and to resolve any events in any manner it deems appropriate regardless of what action, if any, has been taken or recommended by the administrative staff. For patient comments concerning the quality of care or premature discharge, the comments will be referred to the appropriate Utilization and Quality Control Peer Review Organization. (Reference the facility Utilization Management Plan.) In addition to the process specified in this policy, any patient comment regarding physicians may be referred to the Medical Staff for review and resolution.

In an interview with Staff # 1 and Staff # 3 on 7/31/25, it was confirmed , not all the complaints reported in 2025 were reviewed and resolved per the policy above. Review of complaint documentation received from the facility outside source with staff # 3, it was confirmed there was no documentation available that reviewed these complaints.