Pecos County Memorial Hospital

“GOVERNING BODY OR RESPONSIBLE INDIVIDUAL CFR(s): The CAH has a governing body or an individual that assumes full legal responsibility for determining, implementing and monitoring policies governing the CAH’S total operation and for ensuring that those policies are administered so as to provide quality health care in a safe environment. This Standard is not met as evidenced by: 43999 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 .”

“NURSING SERVICES CFR(s): A registered nurse or, where permitted by State law, a physician assistant, must supervise and evaluate the nursing care for each patient, including patients at a SNF level of care in a swing-bed CAH. This Standard is not met as evidenced by: 43999 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.”

“INFECTION PREVENT SURVEIL & CONTROL OF HAIs CFR(s): The infection prevention and control includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and that the program also addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 51020 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.”

“QAPI CFR(s): (b) Standard: QAPI Program Design and scope. The CAH’s QAPI program must: (1) Be appropriate for the complexity of the CAH’s organization and services provided. This Standard is not met as evidenced by: 43999 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.”

“GRIEVANCES CFR(s): § 485.614(a)(2) Grievances The hospital must establish a process for prompt resolution of patient grievances and must inform each patient whom to contact to file a grievance. The hospital’s governing body must approve and be responsible for the effective operation of the grievance process and must review and resolve grievances, unless it delegates the responsibility in writing to a grievance committee. The grievance process must include a mechanism for timely referral of patient concerns regarding quality of care or premature discharge to the appropriate Utilization and Quality Control Quality Improvement Organization. At a minimum: This Standard is not met as evidenced by: 43999 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.”

“EP Training Program CFR(s): §403.748(d)(1), §416.54(d)(1), §418.113(d)(1), §441.184(d)(1), §460.84(d)(1), §482.15(d)(1), §483.73(d)(1), §483.475(d)(1), §484.102(d)(1), §485.68(d)(1), §485.542(d)(1), §485.625(d)(1), §485.727(d)(1), §485.920(d)(1), §486.360(d)(1), §491.12(d)(1). *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, REHs at §485.542, “Organizations” under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For PACE at §460.84(d):] (1) The PACE organization must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing on-site services under arrangement, contractors, participants, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Demonstrate staff knowledge of emergency procedures, including informing participants of what to do, where to go, and whom to contact in case of an emergency. (iv) Maintain documentation of all training. (v) If the emergency preparedness policies and procedures are significantly updated, the PACE must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF’s emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years. This Standard is not met as evidenced by: 43999 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.”

“A Life Safety Code (LSC) Re-Certification Survey was conducted at site on 07/10/25. An entrance conference was held for the CEO and Plant Operations Director on 07/10/25 to discuss the purpose of the LSC survey, and the survey process was explained. Instructions were provided on writing plans of correction. An opportunity was provided for questions and discussion. The LSC survey was conducted under the authority of Chapter 2 of the State Operations Manual, Appendix A, Acute Care Hospitals, 42CFR482 to determine the Hospital’s compliance. An LSC exit conference was conducted on 07/10/25 in the hospital, attended by the Plant Operations Manager. The preliminary findings of the survey and the next steps in the survey process were explained. An opportunity was provided for questions and discussion. Note: The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately.”

“NURSING SERVICES CFR(s): Nursing services must meet the needs of patients. (1) A registered nurse must provide (or assign to other personnel) the nursing care of each patient, including patients at a SNF level of care in a swing-bed CAH. The care must be provided in accordance with the patient’s needs and the specialized qualifications and competence of the staff available. This Standard is not met as evidenced by: 43999 Based on record review and interview, the facility failed to ensure the nursing staff provided the patient one to one observation as ordered by the provider. Findings: Record Review of Patient #1’s medical record revealed Patient #1 was admitted on 12/27/23 for confusion, memory issues. Patient #1 eloped from facility on 12/28/23 unobserved by the facility. Provider order on 12/27/23 indicated one to one observation. Record review of patient #1’s medical record reflected no documented patient observations performed or documented. During an interview with CNO and the Director of Med Surgical Unit on 04/03/24 confirmed the above findings.”