Delta Health System - the Medical Center

“TRANSFER PROTOCOLS CFR(s): Effective July 1, 2025, the hospital must have written policies and procedures for transferring patients under its care (inclusive of inpatient services) to the appropriate level of care (including to another hospital) as needed to meet the needs of the patient. The hospital must also provide annual training to relevant staff regarding the hospital policies and procedures for transferring patients under its care. This Standard is not met as evidenced by: 44086 Based on staff interview, the facility failed to have policy and procedures for transferring inpatient to the appropriate level of care and failed to provide relevant staff with annual training regarding the transferring of patients to the appropriate level of care from inpatient services on three (3) of three (3) days of survey. Findings Include: Interview with Director of Quality, Clinical Education and Regulatory Compliance at 5:28 p.m. on 05/12/2026, confirmed there is no facility policy for transfer of inpatients to an appropriate level of care and no annual training for staff regarding such transfers No policy and procedure for inpatient transfers for review. During an exit conference on 05/13/2026 at 4:00 p.m. the survey team reviewed survey findings with facility staff as listed on the Exit Conference sheet and no further items for review were submitted.”

“DIRECTOR OF REHABILITATION SERVICES CFR(s): 482.56(a)(1) The director of the services must have the necessary knowledge, experience, and capabilities to properly supervise and administer the services. This Standard is not met as evidenced by: 44086 Based on staff interview and personnel file review for the Director of Outpatient Rehabilitation Services, the facility failed to have a Director that is a licensed professional to be able to supervise and administer therapy services and must maintain licensure and certifications required by State law for one (1) of three (3) days of survey. Findings Include: During an interview with The Director of Outpatient Rehabilitation Services on 05/13/2026 at 12:12 p.m. it was confirmed he is not a licensed therapist. The Director of Outpatient Rehabilitation Services further confirmed to be the Director and has been since 2020. During an interview with the Director of Quality on 05/13/2026 at 2:35 p.m. it was confirmed the Director of Outpatient Rehabilitation Services is a non-clinical employee and does not possess a clinical license. Review of the facility Organizational Chart revealed Outpatient Rehab Director reporting to the Chief Financial Officer (CFO). Review of the personnel file for the Director of Outpatient Rehabilitation Services revealed, “Position Description”, signed 11/03/2020, “ ...Position Title ...Director of Outpatient Rehabilitation Services ...Coordinates and supervises operations of the department, administers physical agents prescribed by a referring physician ...Duties and Responsibilities ...Ability to observe and evaluate treatment effect, recommends change to physician if needed ...ability to perform an appropriate assessment on all patients as related to the therapy requested and provided reassessments as per policy ...this includes neonate, pediatric, adolescent, geriatric patients, and the general patient population ...able to assess patient pain ...makes appropriate physician contact for intervention ...performs all aspects of patient care ...Demonstrates Competency ...coordinates and directs patient care to ensure patients’ needs are met and hospital policy is followed ...Regulatory Requirements: 3 or more years of previous experience in aspects of rehabilitative medicine ...current Mississippi Licensure or certification as PT, OTR or speech pathologist; preferred ...knowledge of physical medicine, modalities in their area of specialty ...knowledge of disease processes and related causative factors ...”. During the exit conference on 05/13/2026 at 4:00 p.m. with administrators as listed on the Exit Conference form, survey findings were discussed and no additional information was submitted for review.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 48128 Based on staff interview, medical record review, and policy and procedure reviews, the facility failed to follow their policy and procedure by neglecting to turn Patient #1 every two (2) hours during patient’s hospital stay 09/11/2025 through 09/15/2025 for one (1) of (3) patient records reviewed; Patient #1. Findings Include: Interview with Registered Nurse (RN) #1 on 12/03/2025 at 9:55 a.m. confirmed Patient #1 did not have any skin breakdown or discolored areas on his buttocks area when she performed her admission assessment on 09/11/2025. Review of Patient #1’s medical record from transferring facility dated 09/07/2025 revealed patient had a Stage 1 (one) decubitus ulcer on his sacrum. Review of Patient #1’s medical record “Admission Care Assessment,” completed 09/11/2025 at 5:10 p.m. by RN #1 revealed no documentation of wounds present on admission. Review of Patient #1’s medical record, “Plan of Care” revealed patient was to be monitored for impaired skin integrity, Braden Scale, turning and repositioning every two (2) hours. Review of Patient #1’s medical record “Turning and Repositioning Care Assessments,” revealed patient was turned for the first time on 09/12/2025 at 8:25 p.m., missing 13 turning and repositioning times since his admission on 09/11/2025 at 5:10 p.m. Patient #1 was not turned and repositioned again until 09/13/2025 at 8:00 a.m., missing five (5) turning and repositioning times. Patient was turned on 09/15/2025 at 6:00 a.m. then was not turned again until his discharge at 2:20 p.m., missing three (3) turning and repositioning times. Facility staff failed to turn and reposition patient a total of 21 times during his admission. Review of Patient #1’s Wound Assessment from his home health nurse revealed Patient #1 was admitted to home health 09/20/2025 with one (1) Stage 4 (four) pressure injury to his left buttock, one (1) Stage 3 (three) pressure injury to his mid-sacral region, one (1) Stage 2 (two) pressure injury to his scrotum, and one (1) Stage 2 (two) pressure injury to his penis. Review of the facility’s Braden Scale revealed patients with scores of 15-18 are considered mild risk, scores of 13-14 are considered moderate risk, scores of 10-12 are considered high risk, and scores of less than or equal to nine (9) are considered severe risk. Review of Patient #1’s Braden Scale Assessments and Scores revealed his Braden Scale ranged from 11-15 throughout his admission. Patient received a Braden Scale score of 11 one time, 12 three (3) times, 13 two (2) times, 14 two (2) times, and 15 one (1) time during his admission. Review of facility’s policy and procedure, “Skin Assessment, Documentation, and Treatment,” NS.S.001, Last Approved 05/2025, revealed any patient scoring 12 or below on the skin integrity assessment or identified as at-risk during reassessment will have skin risk protocol implemented and patients should be repositioned every 2 (two) hours and as needed (PRN) for comfort.”

“CONTENT OF RECORD: ORDERS,NOTES,REPORTS CFR(s): 482.24(c)(4)(vi) [All records must document the following, as appropriate:] All practitioner’s orders, nursing notes, reports of treatment, medication records, radiology and laboratory reports, and vital signs and other information necessary to monitor the patient’s condition. This Standard is not met as evidenced by: 31935 Based on staff interviews, medical record review and policy and procedure review, the facility staff failed to document practitioner’s orders, wound care assessment, dressing changes and document of repositioning on a consistent basis to monitor patient’s condition during the inpatient hospital stay from 03/21/2025 to 04/02/2025 for three (3) of three (3) days of survey; Patient #1. Findings Include: During an interview on 04/30/2025 at 10:45 a.m. the Director of Quality confirmed there was inconsistent facility staff documentation of dressing changes and repositioning Patient #1 every two hours in the medical record. During an interview on 04/30/2025 at 11:36 a.m., the RN #2 Day Supervisor confirmed being on duty the dates of 03/29/2025-04/02/2025. The RN Day Supervisor could not recall anyone reporting to her concerning a problem or complaint regarding a patient care. During an interview on 05/01/2025, the Director of Quality confirmed Physician #1 should initiate and identify the recommendations in the orders section of the medical record to complete the physician’s orders, and it is no evidence that this process was completed in the medical record of Patient #1. Review of documentation from Patient #1’s medical record for wound assessments and wound care dressing changes revealed no wound care dressing changes were documented for dates 03/21/2025, 03/24/2025, 03/25/2025 or 03/30/2025. Review of documentation from Patient #1’s medical record revealed on 03/29/2025 Patient #1 was turned and repositioned at 10:12 p.m. and 11:55 p.m., on 03/30/2025 repositioned at 2:43 a.m. and 6:51 a.m. and on 04/01/2025 at 02:26 a.m. was repositioned at 04:41 a.m. and 2:00 p.m. No further documentation was submitted for evidence of repositioning Patient #1 every two (2) hours for Patient #1. Review of Physician #1 progress note titled “Infectious Disease Consult Draft” dated 03/20/2025 revealed for wound care to reposition patient every two hours and cleanse wounds with normal saline and then apply dry dressing daily and when necessary. The only evidence in the “active order section” in the medical records on 03/20/2025 was consult wound care routine. No further documentation submitted regarding a complete order for wound care in the medical record. Review of order section from the medical record revealed on 03/26/2025 Physician #2 documented ...Wound Care: Continue recommendations of Physician #1. No further specific order was submitted for review. Review of facility policy titled “Skin Assessment, Documentation and Treatment, NS.S.001” last revision 07/2022 revealed ... “All patients will automatically be assigned a Braden Skin Risk Assessment score in the electronic health record computer system when the nurse documents the nursing assessment on admission ...All patients skin will be assessed from head to toe during the Nursing Admission Assessment and during each shift for wounds and/or reddened areas. Any wounds will be documented on the Wound Assessment Record ...Any patient scoring 12 or below on the skin integrity assessment or identified as at-risk during reassessment will have skin protocol implemented which is listed below ...Minimize potential damage resulting from mechanical forces such as friction, shear, and pressure ...Reposition every 2 hours and as needed for comfort using turn clock as a guide. Document in the electronic record ...Utilize pillows or positioning wedges to avoid pressure on bony prominences and/or heels ...”. During the exit conference on 05/01/2025 at 1:09 p.m. with Director of Quality, Infection Control Director, Informationist RN, Director of Intensive Care Unit (ICU) survey findings were discussed, and no further documentation was submitted for review.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 31935 Staff Interview, medical record review, facility medication variance report review, and facility policy review confirmed Nursing staff did not follow facility policy and procedures for the timely administration of medications, resulting in medications administered late for four (4) of four (4) sampled patients between 10/28/2024 and 11/04/2024. Patients #1, # 2, #3 and #4. Findings Include: During an interview on 01/15/2025 at 2:20 p.m., the Director of Quality (DOQ) confirmed she was not aware of medications given late until she generated a facility medication Variance report today. The DOQ further confirmed when a scheduled medication is administered greater than 60 minutes before or after due time, the discrepancy will be identified on the variance report. During an interview on 01/16/2025 at 10:30 a.m., the Director of Pharmacy (DOP) confirmed he was only aware of a delay in administering a nephrotoxic antibiotic. Further the DOP revealed he did not realize that other scheduled medications were being administered late until he generated this variance report today. Review of Electric Medication Administration Record (EMAR) Variance Report for Patient #1 revealed on 11/01/2024 and 11/02/2024 the medications Docusate sodium 100 milligrams (mg) twice daily (bid) by mouth (p.o.), Aspirin 81 mg p.o. daily, Ticagrelor 90 mg p.o. bid, Atorvastatin Calcium 40 mg P.O bid were scheduled for 9:00 a.m. but administered after 12:00 p.m. by Registered Nurse (RN) #1. Review of EMAR Variance Report for Patient #2 revealed on 11/01/2024 the medications Pantoprazole Sodium 40 mg Intravenous push (IVP) daily, Digoxin 125 micrograms (mcg) p.o. daily, Torsemide 40 mg p.o. daily, and potassium chloride 20 milliequivalent (meq) p.o. daily was scheduled for 9:00 a.m. but was administered after 12:00 p.m. by RN #1. Review of the EMAR Variance Report for Patient #3 revealed on 10/31/2024 and 11/01/2024, the medications Pantoprazole Sodium IV 40 mg IVP daily, Prednisone 20 mg p.o. daily, Spironolactone 50 mg p.o. daily, Sacubitril/Valsar 24 mg/26mg p.o. daily, were scheduled for 9:00 a.m. but were administered at 11:01 a.m., and on 11/01/2024 the medication Piperacillin Sodium/Tazobactam 3.375 grams in 9% Sodium Chloride Intravenous Piggy Back (IVPB) was scheduled for 10:00 a.m. , was not administered until after 12:30 p.m. by RN #2. Review of the EMAR Variance Report for Patient #4 revealed on 10/31/2024 and 11/01/2024, the medications Nifedipine XL 60 mg p.o. daily, Spironolactone 25 mg p.o. bid., Tamsulosin HCL 0.4 mg p.o. bid, Aspirin 81 mg, p.o. daily, Lisinopril 20 mg p.o. bid and Metoprolol Tartrate 50 mg bid were scheduled for 9:00 a.m. and was not administered until after 12:30 p.m. by RN #3. Review of facility policy entitled “Medication Orders, PH.022,” last review date 12/2023 revealed “ ...scheduled medications include all maintenance doses administer according to a standard, repeated cycles of frequency ...Medicine schedules should only be altered when absolutely unavoidable. Scheduled medications are considered to be “late” when given more than one hour before or after the time the dose is due to be administered ... Time-critical medications are those where early or delayed administration of maintenance doses of greater than 30 minutes before or after the scheduled dose may cause harm or result in substantial sub-optimal therapy or paralogical effect ...defines such medications as: Antibiotics, Anticoagulants, Insulin, Anticonvulsants, Immunosuppressive Agents, Scheduled Pain Medications ...”. The Exit conference was conducted on 01/16/2024 at 12:10 p.m. with the Chief Nursing officer and Director of Quality. No other documents were submitted from the facility.”