HospitalInspections.org

Based on observations and interviews with staff during a tour of the hospital and off site locations by Life Safety Code surveyors, it was determined the hospital was not constructed, arranged and maintained to ensure patient safety.

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

Findings include:

Refer to tags: K-0211, K-0226, K-0325, K-0351, K-0353, and K-0923.

Based on Medical Record (MR) review, hospital policy and procedure, and staff interview it was determined the hospital failed to follow the hospital's occurrence report policy and document all grievances reported to the staff.

This deficient practice did affect MR # 19 and had the potential to affect all patients and families served by this hospital.

Findings include:

Hospital Policy: Occurrence Report- Quality Assurance

Policy number: 1863931

Revision date: 8/2025

Purpose: Quality Assurance (QA) Occurrence Reporting contributes to the maintance of a safe environment. Documented occurrences are reviewed and analyzed for development of loss prevention measures and process improvement action under the aspects of QA Laws of the State of Alabama.

Definitions: An Event or Occurrence is:

Any happening which is not consistent with the routine operation of the hospital or the routine care of a particular patient...

2. Any unexpected or untoward event. It is any event or situation, which may or may not result in damage of property or illness/injury to a patient, visitor, or employee...

Objectives:

1. To document all occurrences involving patients, visitors, employees, property damage and/or loss...

Policy/Procedure:

1. The report must be completed as soon after the occurrence as possible, but no later than the end of the shift in which the occurrence happened or was discovered.

2. The report is a factual description of the occurrence...

4. The person first on the scene, observing, discovering, or directly involved shall complete the QA occurrence report.

1. PI # 19 was admitted to the hospital on 6/28/25 with diagnoses including Acute Appendicitis and Congestive Heart Failure.

A review of the MR revealed the staff documented in the Patient Progress Notes dated 7/3/25 "...Pt's son [Name] came in unit requesting for his father to be transferred. States "My attorney informed me to get him out of here" Mr [Name] complaints of previous care. Feels could have been prevented if someone had came in to his room. Supervisor present and talking with him. Dr [Name] informed also..."

A review of the Compliant and Grievance log revealed no documentation of this occurrence.

An interview was conducted on 9/25/25 at 3:11 PM with Employee Indentifer # 11, Intensive Care Unit Nurse Manager, who confirmed there was no documentation the grievance was investigated and the patient/caregiver notified of the results of the investigation..

Based on review of the hospital QAPI (Quality Assurance and Performance Improvement) program documentation, hospital policy and interviews, it was determined the facility QAPI program failed to include reporting data for each department of the facility.

This deficient practice had the potential to affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Dale Medical Center Quality/Performance Improvement (PI) Plan 2025

Policy Number: Not Listed

Approved: 2/19/25

... The purpose of Performance Improvement is to ensure that patients are provided high quality care in an environment with minimal risk that focuses on patient safety...

The leaders will set priorities for organization wide performance improvement activities...

I. Departmental/Services:

1. Every department/service at Dale Medical Center is included in the Performance Improvement Program...

1. A review of the QAPI data for the year 2024 and 2025 revealed no documentation of data collection and no documentation of QAPI participation from each hospital department, including Dietary, Maintenance, Physical Therapy, and Emergency Preparedness.

An interview was conducted on 9/25/25 at 1:10 PM with Employee Identifier # 1, Director of Quality and Risk Management, who confirmed there was no documentation of participation in the QAPI program from each hospital department.

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

1. Wound care was provided as ordered.

2. Wounds were assessed and measured per hospital policy.

3. Physician's orders were complete with the wound care to be performed.

4. Vital Signs (VS) were assessed as ordered by the physician.

This deficient practice affected six of 20 inpatient MR reviewed including Patient Identifier (PI) # 6, PI # 10, PI # 4, PI # 12, PI # 5, and PI # 19, and had the potential to negatively affect all patients admitted to this hospital.

Findings include:

Hospital Policy: Wound Care - Orders, Treatment, Frequency and Wound Type

Policy Number: 14715662

Revised: 12/2023

Policy:

Dressings for patient wound care will be managed according to physician order.

A physician's order shall be obtained prior to changing dressings. The order shall include:

Kind of dressing

Wound cleansing agent

Medication or solution, frequency, dosage, ... to be used...

Frequency of dressing change...

Assessment: Should be performed once per shift...

Hospital Policy: Wound/Pressure Ulcer Measuring & Photographing

Policy Number: 14715378

Revised: 12/2023

...Policy: A Registered Nurse or Physical Therapist will measure pressure ulcers/wounds upon initial assessment...then...weekly thereafter...

Facility Policy: Orders-Computerized Physician Order Entry (CPOE), Verbal, Written, PO (Phone Order).

Policy number: 13586484

Revised: 5/2023

...Written orders that have been placed in the patient chart to be acknowledged by staff, entered into the CPOE, and carried out by nursing staff. Physician orders, issued usually electronically through the CPOE system, and acknowledged by nursing staff, and carried out.

1. PI # 6 was admitted to the Swing Bed Unit on 9/9/25 with a diagnosis of Small Bowel Obstruction.

Review of the physician's order dated 9/9/25 revealed orders for "Wound care." The order did not include a location of the wound, what wound was to be cleaned with, what dressing was to be used and no documentation of the frequency the wound care was to be performed.

Review of the Multi-Disciplinary Assessment dated 9/12/25 revealed the nurse documented the presence of a Stage 2 pressure injury to lower left buttock measuring 1 centimeter (cm) in length, 1 cm in width, and 0.1 cm in depth.

Review of the physician's order dated 9/12/25 revealed orders to "Clean and dress buttocks wounds daily." The order did not include what the wound was to be cleaned with or what dressing was to be used.

Review of the Skilled Nurse (SN) Patient Progress Notes (PPN) dated 9/13/25 and 9/14/25 revealed no documentation wound care was provided daily to the buttocks.

Review of the physician's order dated 9/15/25 revealed orders to clean reddened areas to perineum, gluteal folds and thigh folds with Chlorhexidine solution, pat dry, then apply Butt Paste with Nystatin cream, and cover with Dry Sheets twice daily.

Review of the SN PPN dated 9/18/25 and 9/19/25 revealed wound care to the buttocks was performed once a day, not twice a day as ordered.

Review of the SN PPN dated 9/20/25, 9/21/25, and 9/22/25 revealed no documentation wound care was provided.

An interview was conducted on 9/25/25 at 2:35 PM with Employee Identifier (EI) # 10, Director of New Day, who confirmed the physician's orders did not include the location of the wound, the care or frequency to be provided, and the staff failed to follow the physican's orders for wound care.

2. PI # 10 was admitted on 9/22/25 with diagnoses including Abdominal Pain, Urinary Tract Infection, and Pelvic Fracture.

Review of the Physician Order dated 9/23/25 at 7:48 AM revealed physician's orders for daily wound care to pressure wound, clean with Vashe wound solution, apply Santyl to necrotic areas, then wet to dry dressing with Vashe solution and non-woven gauze, cover with abdominal (ABD) pad, and secure with Hypafix tape.

Review of the SN PPN dated 9/23/25 at 7:00 PM revealed the SN documented the pressure wound was cleaned with wound cleanser and Chlorhexidine wash, Santyl ointment was applied, wound was packed with saline soaked gauze, Telfa pad was applied to the wound, covered with 4 x 4 gauze, then taped in place with paper tape.

An interview was conducted on 9/25/25 at 2:20 PM with EI # 9, Medical Surgical Unit Manager, who confirmed the staff failed to follow the physician's orders for wound care.




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3. PI # 4 was admitted to the New Day Behavioral Unit on 9/19/25 with a primary diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of Physician Entered Orders (PEO) revealed a Nursing Order (NO) dated 9/19/25 for VS every 12 hours with Oxygen Saturation (SPO2) checks.

Review of the Graphic and Intake and Output (I & O) revealed VS and SPO2 were not obtained every 12 hours on 9/20/25, per the physician's order.

Further review of the Graphic and I & O revealed no Output was documented on 9/21/25.

An interview was conducted on 9/25/25 at 3:08 PM with EI # 2, Chief Nursing Officer, who confirmed VS (including I & O) and SPO2 were not obtained every 12 hours per physician's order.

4. PI # 12 was admitted to the New Day Behavioral Unit on 9/7/25 with a primary diagnosis of Schizoaffective Disorder.

Review of the PEO revealed a NO dated 9/7/25 for VS every 12 hours with SPO2.

Review of the Graphic and I & O revealed on 9/9/25, 9/10/25, 9/11/25, 9/12/25, 9/13/25, 9/14/25, 9/16/25, 9/17/25, and 9/18/25, VS and SPO2 were not obtained every 12 hours per the physician's order.

Further review of the Graphic and I & O revealed there was no Input documented on 9/12/25.

An interview was conducted on 9/25/25 at 3:00 PM with EI # 10, who confirmed VS (including I & O) and SPO2 were not documented every 12 hours per the physician's order.




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5. PI # 5 was admitted on 9/17/25 with diagnoses including Hip Fracture and Hypertensive Heart Disease with Heart Failure.

Review of the Physician Order dated 9/18/25 at 11:51 AM revealed physician's orders for daily wound care to surgical incisions times three, clean with wound cleanser, pat dry, apply Xeroform gauze, cover with non-adherent Telfa pad, then ABD pad, and secure with Hypafix tape.

Review of the SN PPN dated 9/22/25 at 5:12 PM revealed the SN documented the surgical incisions were cleaned with wound cleanser, Xeroform was applied, then covered with 4 X 4 gauze and ABD pad, and secured with Hypafix tape.

Review of the SN PPN dated 9/18/25 revealed no documentation wound care was provided.

An interview was conducted on 9/25/25 at 2:18 PM with EI # 1, Director of Quality/Risk Management/Safety Officer who confirmed the staff failed to follow the physician's orders for wound care.


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6. PI # 19 was admitted to the hospital on 6/28/25 with diagnoses including Acute Appendicitis and Congestive Heart Failure.

A review of the MR revealed the patient was admitted with documented and photographed wounds on the coccyx and right foot.

A review of the physician's orders dated 6/28/25 to 7/7/25 revealed no orders for wound care for the documented wounds listed above.

A review of the SN PPN dated 6/28/25 to 7/7/25 revealed no documentation of measurements of the Coccyx, and right foot wound.

A review of the SN PPN wound care dated 6/29/25, 7/1/25, 7/2/25, 7/3/25, 7/5/25, and 7/7/25 revealed wound care performed to the right foot by the staff. There was no physician's order for wound care to the right foot.

An interview was conducted on 9/25/25 at 3:11 PM with EI # 11, Intensive Care Unit Nurse Manager, who confirmed the staff failed to follow the wound care policy and provided wound care to the patient without an order.

Based on review of medical records (MR), hospital policies and procedure, and staff interview, it was determined the hospital failed to ensure staff followed the hospital policy for administration of "as needed" (PRN) drugs.

This deficient practice affected Patient Identifier (PI) # 4, PI # 12, and PI # 14 in three of twenty inpatient MRs reviewed and had the potential to negatively affect all patients receiving PRN medications.

Findings include:

Hospital Policy: Medication Administration

Policy Number: 18458034

Revised: 7/2025

...C. Medication Administration

...2. Prepare the medication:

...j. document administration of medication

k. Reassess the patient to evaluate response and any adverse side effects.

Hospital Policy: Pain Assessment, Reassessment, and Management

Policy Number: 17105609

Revised: 12/2024

...Procedure...

Any patient care provider...that has implemented a pain control mechanism, will reassess the patient within one hour to determine amount of pain control or relief achieved.

1. PI # 4 was admitted to the facility on 9/19/25 with a diagnosis of Schizoaffective Disorder, Bipolar Type.

Review of the Physician Entered Orders (PEO) revealed an order dated 9/20/25 for Vistaril (Hydroxizine Pamoate) 50 milligrams (mg) by mouth every six hours PRN. Orders did not state the reason for the PRN medication.

Review of the Medication Record revealed PRN Vistaril was administered on 9/20/25, 9/21/25, and 9/22/25. There was no documentation the PRN Vistaril was reassessed after administration.

An interview was conducted on 9/25/25 at 3:08 PM with EI # 2, Chief Nursing Officer, who confirmed PRN medications were not reassessed after administration per the hospital policy.

2. PI # 12 was admitted to the facility on 9/7/25 with a primary diagnosis of Schizoaffective Disorder.

Review of the PEO revealed the following medication orders:

Geodon (Ziprasidone) 20 mg injection every eight hours PRN dated 9/9/25. Orders did not state the reason for the PRN medication.

Benadryl (Diphenhydramine) 50 mg injection every eight hours PRN dated 9/9/25. Orders did not state the reason for the PRN medication.

Review of the Medication Record revealed the following:

PRN Geodon was administered on 9/10/25, 9/15/25, and 9/17/25. There was no documentation the PRN Geodon was reassessed after administration.

PRN Benadryl was administered on 9/14/25 and 9/15/25. There was no documentation PRN Benadryl was reassessed after administration.

An interview was conducted on 9/25/25 at 3:00 PM with EI # 10, Director of New Day Behavioral Unit, who confirmed PRN medications were not reassessed after administration per the hospital policy.

3. PI # 14 was admitted to the facility on 7/1/25 with a diagnoses including Closed Head Injury, Blunt Abdominal Trauma, Supraventricular Tachycardia, and Urinary Retention.

Review of the PEO revealed orders for the following:

Zofran (Ondansetron Hydrochloride) 4 mg Intavenous Push every four hours PRN nausea dated 7/1/25.

Norco (Hydrocodone/Acetaminophen) 5 mg by mouth every 4 hours PRN pain dated 7/2/25.

Review of the Medication Record revealed the following:

PRN Zofran was administered on 7/1/25. There was no documentation the PRN Zofran was reassessed after administration.

PRN Norco was administered on 7/3/25. There was no documentation the PRN Norco was reassessed within one hour after administration.

An interview was conducted on 9/25/25 at 3:06 PM with EI # 1, Director of Quality/Risk Management/Patient Safety Officer, who confirmed staff failed to reassess the patient within one hour after PRN medication administration per the hospital policy.

Based on a Dietary manual review, and staff interview it was determined the hospital failed to maintain a current dietary manual approved by the dietitian and medical staff.

This deficient practice had the potential to affect all patients served by the hospital's dietary service.

Findings include:

A review of the dietary manual revealed the published date of 2014 and no current signature of the dietician or evidence of approval by medical staff.

An interview was conducted on 9/25/25 at 2:14 PM with Employee Indentifer # 13, Facilities Director, who confirmed the Dietary Manual date of 2014 and no documented signature of the dietician or approval of medical staff.

Based on observations, hospital policy, and staff interview, it was determined the hospital failed to ensure staff performed hand hygiene per the facility policy.

This affected Patient Identifier (PI) # 10 , PI # 9, PI # 7, PI # 18, PI # 6, PI # 33, and one unsampled patient in seven of nine observations of patient care on the medical surgical unit and one of one observation in the surgical unit, and had the potential to negatively affect all patients receiving patient care in this hospital.

Findings include:

Hospital Policy: Hand Hygiene

Policy Number: 12610377

Revised: 01/2020

Policy:

All staff should use the hand hygiene techniques, ...

Before coming on duty, when hands are soiled, before each patient encounter, ...before applying gloves..., after coming in contact with patient's intact skin, after working on a contaminated body site and then moving to a clean body site of the same patient, after coming in contact with bodily fluids, dressings, mucous membranes...and hands are not visibly soiled, after contact with medical equipment/supplies in patient areas, always after removing gloves or facemasks, ...

1. An observation was conducted on 9/23/25 at 2:38 PM with Employee Identifier (EI) # 3, Registered Nurse, administering an intravenous (IV) antibiotic to PI # 10.

After documenting in the electronic health record (EHR) and scanning the patient's wrist band and medications, EI # 3 failed to change gloves and perform hand hygiene before accessing the bag of IV antibiotic and connecting it to the patient's indwelling IV catheter.

EI # 3, failed to perform hand hygiene one time before donning gloves and one time after removing gloves during the medication administration.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, Director of Quality/Risk Management/Patient Safety Officer, who confirmed staff failed to perform hand hygiene per hospital policy.

2. An observation was conducted on 9/24/25 at 8:20 AM with EI # 3 administering oral medications to PI # 9.

After documenting in the EHR, scanning the medications and the patient's wrist band, EI # 3 failed to change gloves and perform hand hygiene before opening and administering the patient's oral medications.

After administering the patient's medications, EI # 3 failed to remove his/her gloves and perform hand hygiene before documenting in the EHR.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

3. An observation was conducted on 9/24/25 at 8:35 AM with EI # 3 changing the IV access site for PI # 9.

After documenting in the EHR, EI # 3 failed to perform hand hygiene before donning gloves.

EI # 3 failed to change gloves and perform hand hygiene after he/she removed the dressing from the old IV site and discontinued the IV and before preparation and insertion of the new IV site.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

4. An observation was conducted on 9/24/25 at 9:45 AM with EI # 4, Licensed Practical Nurse (LPN), administering oral medications and an IV antibiotic to PI # 7, who was on isolation precautions due to having COVID.

EI # 4 failed to perform hand hygiene prior to donning his/her personal protective equipment.

EI # 4 scanned the medications and failed to perform hand hygiene before donning gloves and administering the oral medications.

EI # 4 failed to don gloves before connecting the IV tubing to the antibiotics and accessing the patient's indwelling IV catheter.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

5. An observation was conducted on 9/24/25 at 10:20 AM with EI # 12, Patient Care Technician, obtaining a blood glucose level for PI # 18.

EI # 12 failed to perform hand hygiene before donning gloves one time during the observation.

EI # 12 failed to perform hand hygiene after removing gloves at the completion of the blood glucose check.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

6. An observation was conducted on 9/24/25 at 10:30 AM with EI # 5, LPN, performing wound care for PI # 6.

EI # 5 removed his/her gloves five times, and without performing hand hygiene, donned new gloves.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

7. An observation was conducted on 9/24/25 at 11:03 AM of a Left Shoulder Arthroscopy for PI # 33.

EI # 7, Certified Registered Nurse Anesthetist, performed hand hygiene, donned gloves, administered Xyocaine 2% intravenous (IV), Ropivaccaine 0.5% IV, then removed gloves, and donned sterile gloves. EI # 7 failed to perform hand hygiene after removing gloves and prior to donning sterile gloves.

An interview was conducted on 9/25/25 at 2:18 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.

8. An observation was conducted on 9/24/25 at 2:55 PM with EI # 6, Respiratory Therapist, administering a nebulizer treatment (inhaled medication), to an unsampled patient.

EI # 6 failed to perform hand hygiene three times during the nebulizer treatment.

An interview was conducted on 9/25/25 at 2:30 PM with EI # 1, who confirmed staff failed to perform hand hygiene per hospital policy.





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Based on observation, hospital policy and procedure, and staff interview it was determined the hospital failed to ensure the staff followed the Hand Hygiene policy and procedure.

This deficient practice had the potential to affect all patients, visitors, and employees served by the dietary department.

Findings include:

Hospital Policy: Hand Hygiene

Policy number: 12610377

Revision date: 11/2022

Purpose:
To provide guidelines for effective hand hygiene, in order to prevent the transmission of bacteria, germs,and infections and for maintaining patient and healthcare personnel safety...

Policy:
All staff should use the hand-hygiene techniques, as set forth in the following procedure...

* Before coming on duty.
* When hands are soiled...
* Always after removing gloves or facemask...


1. An observation was performed in the kitchen on 9/24/25 at 11:25 AM during the plating of the patient dietary trays.

The five staff members observed were changing gloves frequently and not performing hand hygiene before putting on clean gloves, during the plating of patient dietary trays.

An interview was conducted on 9/25/25 at 1:45 PM with Employee Identifier # 14, Infection Prevention Nurse, who confirmed the staff did not follow the hospital policy regarding hand hygiene.

Based on a review of the hospital's Emergency Preparedness plan, and staff interview, it was determined the hospital failed to update and or review the hospital's emergency preparedness plan every two years.

This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital.

Findings include:

A review of the emergency preparedness plan revealed the last documented review of the plan was performed in September of 2022.

An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan had not been reviewed or updated since September 2022.

Based on a review of the hospital's All Hazards Risk Assessment and staff interview, it was determined the hospital failed to fully complete a hospital-based and community-based risk assessment, utilizing an all-hazards approach.

This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital.

Findings include:

A review of the all-hazards risk assessment revealed the assessment included a cyber attack, transportation failure, and a snow storm. No date was listed on the form for the assessment.

An interview was completed on 9/25/25 at 2:20 PM with Employee Identifier # 2, Chief Nursing Officer, who confirmed the all hazards risk assessment presented to the surveyor included all hazards that were assessed for this hospital. The hospital failed to complete an assessment to include all hazards likely to affect this hospital.

Based on a review of the hospital's emergency preparedness plan, and staff interview, it was determined the hospital failed to have a system to track the location of on-duty staff and sheltered patients in the care of the hospital during an emergency.

This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital.

Findings include:

A review of the emergency preparedness plan revealed no documentation of a system to track on-duty staff and sheltered patients in the care of the hospital during an emergency.

An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan did not have a system to track on-duty staff and sheltered patients in the care of the hospital during an emergency.

Based on a review of the hospital's emergency preparedness plan, and staff interview, it was determined the hospital failed to develop arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.

This deficient practice had the potential to affect all patients, staff, and vistors served by this hospital.

Findings include:

A review of the emergency preparedness plan revealed no documentation of arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.

An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan did not have arrangements with other hospitals and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to hospital patients.

Based on a review of the hospital's emergency preparedness plan, and staff interview, it was determined the hospital failed to develop a communication plan, and update it and or review it at least every two years.

This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital.

Findings include:

A review of the emergency preparedness plan revealed no documentation of a communication plan.

An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the emergency preparedness plan failed to include a communication plan.

Based on a review of the hospital's emergency preparedness plan, and staff interview, it was determined the hospital failed to have a tabletop exercise or record an actual event during the 2024 year.

This deficient practice had the potential to affect all patients, staff, and visitors served by this hospital.

Findings include:

A review of the emergency preparedness plan revealed no documentation of a tabletop exercise or actual event during the 2024 year.

An interview was conducted on 9/25/25 at 1:58 PM with Employee Identifier # 13, Facilities Director, who confirmed the hospital failed to have a tabletop exercise or actual event during the 2024 year.