HospitalInspections.org

Based on medical record (MR) review, hospital policy and procedures, and staff interview, it was determined the hospital failed to ensure nineteen of thirty patients were informed of the patient's rights and responsibilities prior to receiving care at the hospital.

This had the potential to negatively affect all patients served by this hospital.

Findings include:

Hospital Policy: Patient Rights and Responsibilities Policy and Procedure
Policy Number: None Listed
Reviewed Date: 10/26/24

...Purpose:

To define and communicate the rights and responsibilities of patients receiving care... and to ensure all staff uphold these rights in accordance with legal and ethical standard.

...4. Documentation:

Acknowledgement of receipt of Patient Rights and Responsibilities is documented in the patient's medical record.

Review of the MR's of Patient Identifier (PI) # 2, PI # 4, PI # 5, PI # 7, PI # 8, PI # 9, PI # 10, PI # 12, PI # 13, PI # 21, PI # 22, PI # 23, PI # 24, PI # 25, PI # 26, PI # 27, PI # 28, PI # 29, and PI # 30 revealed there were no verbal or signed patient rights completed.

An interview was conducted on 6/18/25 at 1:30 PM with Employee Identifier (EI) # 3, Director of Nursing, who confirmed the staff failed ensure the patients were informed of the patient's rights and responsibilities prior to receiving care at the hospital.

Based on medical record (MR) review, hospital policies and procedures, and interviews with staff it was determined the hospital failed to ensure:

1. Wounds were assessed and measured per hospital policy.

2. Wound care was provided per physician's orders.

3. Physician was notified of new wounds.

This deficient practice affected two of five patients with wounds including Patient Identifier (PI) # 8, and PI # 7, and had the potential to affect all patients with wounds admitted to this hospital.

Findings include:

Hospital Policy: Wound Care Policy and Procedure

Policy Number: Not Listed

Reviewed: 1/8/24

Policy Statements:

1. A patient and wound assessment must be completed and documented within 24 hours of admission...

2. A wound assessment must be completed and documented with every dressing change...

3. Wound assessments include:

...c. wound size including the longest length, widest width, and deepest depth...

4. Perform a wound assessment with every dressing change:

a. Clean wound prior to assessment.

b. Take wound measurements on admission, at least once a week (every seven days)...

1. PI # 8 was admitted to the hospital Swing Bed on 6/2/25 with diagnoses including Parkinson's Disease, Abnormal Gait, and Asthenia.

Review of the physician's order dated 6/2/25 revealed orders for wound care to the right ankle and left heel every 48 hours. Cleanse wound with saline, cover with Hydrofera Blue, apply gauze, and wrap with Kerlix.

Further review of the physician's order dated 6/2/25 revealed orders to measure wounds on initial observation and every seven days.

Review of the nursing documentation dated 6/3/25 revealed the nurse documented the presence of a vascular ulcer to the left ankle. The nurse further documented the wound was cleansed and dressing applied.

There was no documentation of wound measurements of the new wound.

There was no documentation the nurse notified the physician of the new wound and no documentation of a physician order for wound care to the left ankle.

Further review of the nursing documentation on 6/2/25 revealed the nurse documented the presence of a Stage 2 venous stasis ulcer to the left heel and a Stage 2 pressure ulcer to the lateral right ankle.

There was no documentation the wounds were measured on admission to Swing Bed and no documentation the wounds were measured every seven days.

An interview was conducted on 6/18/25 at 11:30 AM with Employee Identifier (EI) # 1, Administrator, who confirmed the wound care was provided without a physician's order and wound measurements were not obtained per hospital policy.

2. PI # 7 was admitted to the Swing Bed unit on 6/13/25 with diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and Cellulitis of Lower Leg.

Review of the Wound Care Flow Sheet dated 6/14/25 revealed the nurse documented a new Stage 2 Pressure Ulcer between the gluteal folds. The wound was cleansed, skin protectant, and Mepilex dressing applied.

There was no documentation the physician was notified of the new wound and no documentation of a wound care order.

An interview was conducted on 6/18/25 at 11:42 AM with EI # 1 who confirmed the staff failed to notify the physician of the new wound and provided wound care without a physician's order.

Based on medical record (MR), hospital policy, and interviews with staff, it was determined the hospital failed to ensure orders for wound care were complete.

This deficient practice did affect two of five patients with wounds including PI (Patient Identifier) # 7, and PI # 18 and had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Wound Care Policy and Procedure

Policy Number: Not Listed

Reviewed: 1/8/24

...Standards of Care:

...Wound care orders:

All wound care orders must be complete in that they list:

1. Frequency of dressing change

2. Cleaning solution used in wound care procedure

3. Type of dressing to use...

4. Type of securement needed...

1. PI # 7 was admitted to the Swing Bed unit on 6/13/25 with diagnoses including Type 2 Diabetes Mellitus, Essential Hypertension, and Cellulitis of Lower Leg.

Review of the Wound Care Flow Sheet dated 6/14/25 revealed the nurse documented the presence of a Stage 2 Pressure Ulcer between the gluteal folds and wound care was provided including cleansing the wound and applying Mepilex dressing.

There was no documentation of a physician order for wound care to the gluteal folds.

Review of the Physician's Order dated 6/17/25 revealed orders for wound care every three days, clean with Vashe, apply Mepilex now.

There was no documentation in the physician's order of the location of the wound.

An interview was conducted on 6/18/25 at 11:42 AM with Employee Identifier # 1, Administrator, who confirmed the wound care order was not complete.




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2. PI # 18 was admitted to the hospital on 2/6/25 with diagnoses including Altered Mental Status, Gangrenous Pressure Injury Sacrum, and Sepsis.

Review of the Wound Care Flowsheet revealed wound care was documented on 2/6/25 at 6:25 PM and 2/7/25 at 11:30 AM.

Review of the physician's order dated 2/07/25 revealed, Measure Wound on Initial Observation and Every Seven Days- Document Not Due on Days Other Than Initial and 7th.

There was no physician's order for the wound care provided.

An interview was conducted on 6/18/25 at 1:25 PM with EI # 3, Director of Nursing, who confirmed there was no documentation of a physician's order for the wound care provided.

Based on observations, hospital policy and procedures, and interview, it was determined the Dietary Director failed to ensure staff followed the policy and procedure for checking freezer temperatures and record actions taken when above zero degrees Fahrenheit (F).

This had the potential to affect all patients admitted to the hospital.

Findings include:

Hospital Policy: Food Storage Temperature Logs
Policy Number: DS.IV-16
Policy Reviewed: 6/12/24

Purpose:

In order to prevent food borne illnesses, foods should be stored at proper temperatures...

Process:

...b. Action should be taken and noted if temperatures are not in the recommended ranges:

...Freezers -10 to 0 degrees F.

A tour of the dietary department was conducted on 6/16/25 at 10:25 AM with Employee Identifier (EI) # 5, Dietary Director.

Review of the freezer temperature logs for the months of January 2025 to June 2025 revealed freezer temperature readings were out of range in the PM (afternoon) without notification of actions taken, as follows:

January 1st to 31st, three days were recorded with temperatures of 8 degrees F, one day 10 degrees F and four days 18 degrees F.

February 1st to 28th, five days were recorded with temperatures of 8 degrees F, and four days 10 degrees F.

March 1st to 31st, nine days were recorded with temperatures of 8 degrees F, and 12 days with 10 degrees F.

April 1st to 31st, three days were recorded with temperatures of 8 degrees F, two days with 9 degrees F and two days with 10 degrees F.

May 1st to 31st, five days were recorded with temperatures of 8 degrees F, nine days with 10 degrees F, three days with 11 degrees F, and one day with 12 degrees F.

June 1st to 16th, six days were recorded with temperatures of 8 degrees F and four days with 10 degrees F.

An interview was conducted on 6/16/25 at 11:00 AM with EI # 5, who confirmed the staff failed to follow the hospital policy for checking freezer temperatures and note actions taken when above zero degrees F.

Based on observation, hospital policy and procedure and staff interviews, it was determined the hospital failed to ensure expired or opened sterile supplies were not available for patient use.

This had the potential to negatively affect all patients served by the hospital.

Findings include:

Hospital Policy: Management of Expired Supplies

Review Date: 09/21/2024

Policy Number: None

Policy Statement:

It is the policy of Hale County Hospital to ensure expired medical and non-medical supplies are identified, removed, documented and disposed of promptly and safely in accordance with hospital protocols, manufacturer guidelines, and regulatory requirements to prevent patient harm.

Procedure:

1. Routine Checks

- Designated staff will inspect supply areas monthly.
- Expired items will be ... removed immediately...

1. A tour of the Emergency Department was conducted on 6/16/25 at 10:00 AM with Employee Identifier (EI) # 6, Registered Nurse (RN).

Located in the Trauma Room the following supplies were observed expired and available for use:

a. Lumbar Puncture Tray with an expiration date of 9/30/24.

b. Argyle Trocar Catheter 20 French with an expiration date of 7/31/24.

c. Two Argyle Trocar Catheters 32 French with an expiration date of 7/31/24.

An interview was conducted on 8/16/25 at 11:00 AM with EI # 6 who confirmed the items listed were expired and available for use.

2. A tour of the Medical-Surgical (Med-Surg) Unit was conducted on 6/16/25 at 10:12 AM with EI # 2, Infection Prevention Coordinator.

An observation of the supply room revealed the following items expired or open and available for patient use.

a. One Smith Medical Pro-Vent Arterial Blood Sampling Kit with an expiration date of 2/28/24.

b. Two Becton Dickinson (BD) Insite Autoguard 18 g (gauge) x (by) 1.16 inch intravenous (IV)catheters with an expiration date of 9/30/24.

c. Two Cardinal Health IV Start Kits labeled as contents sterile, open and available for patient use.

EI # 2 confirmed at the time of the observation, the items were expired and the two IV start kits were open and all were available for patient use.

An observation of the Utility Room revealed:

a. Three iClean Sample Collection Kits with an expiration date of 3/26/25.

EI # 4, Med-Surg RN, confirmed at the time of the observation, these items were expired and available for patient use.










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Based on review of the personnel files, and interview with staff, it was determined the hospital failed to ensure the staff received training on Emergency Preparedness (EP) a minimum of every two years.

This affected two of five hospital employees and one of one contracted staff personnel files reviewed and had the potential to affect all patients served by the hospital.

Findings include:

Review of the personnel files provided revealed no documentation the hospital employees and contracted staff completed EP training every two years.

An interview was conducted on 6/18/25 at 1:48 PM with Employee Identifier (EI) # 1, Administrator, who confirmed the hospital failed to ensure staff received EP training at a minimum of every two years.