HospitalInspections.org

Based on a review of facility documentation and staff interviews, the hospital governing body failed to develop and approve hospital policies, as stated in their bylaws. The governing body also failed to ensure that the hospital followed current nationally accepted standards of practice such as the CDC (Centers for Disease Control & Prevention) infection control guidelines. These deficient practices had the potential to negatively impact patients health, well-being, and life, as well as that of staff and visitors, through the exposure to a potentially deadly virus.

Findings were:


A. The hospital governing body failed to develop and approve hospital policies as stated in their bylaws:

A review of the Ector County Hospital District Board of Directors By-Laws, approved 9/6/11, revealed the following:

" ...Definitions ...
7. "Governing Body" - means the Board of Directors of the Ector County Hospital District ...

Article III Duties of the Board of Directors

3.01 The Board of Directors shall have and exercise all rights, powers, duties, and obligations in accordance with the laws of the State of Texas, including the responsibility for the general management, control, and administration of Medical Center Health System and other District facilities and the grounds, buildings, equipment, offices, employees, funds, and resources of the District. The Board shall have the responsibility for establishing policy, maintaining quality patient care, and providing for institutional management and planning ..."


In an interview with the Director of Infection Control & Prevention, Staff #5, on the morning of 6/8/21 at approximately 10:00 a.m., in the hospital conference room, she said that she had been in her current position since December 2017.

She described the decision-making process to discontinue requirements for visitors and staff to wear masks. "We have a committee - our exposure committee. We had been meeting and discussing it for several months now..." She added, "the decision was that we recommended the staff use masks, but they could take them off in certain situations. Personnel had complained about wearing the masks because of the irritation to the ears and face... We decided to have it be okay not to wear masks unless the staff is doing direct patient care. We'd continue to recommend wearing masks ... And it was so hard to enforce with visitors ... All the changes were effective 6/1/21."

When asked if that's when screening visitors for COVID-19 exposure and symptoms stopped, she said, "Yes." She also said, "we were aware of the CDC guidelines, but it was just really hard to police it ..."

When asked who was on the exposure committee, she said it included "someone from employee health, someone from HR (human resources), the CNO and other nursing management, as well as others." She also said that the policy changes would have been forwarded to the HIMT (Hospital Incident Management Team) committee and the governing board.

Surveyors requested minutes of the meetings of the governing board, HIMT committee, and exposure committee in which the policy changes that went into effect on 6/1/21 were approved. Staff #5 said that she did not have minutes for the exposure committee as it was an informal committee. Though she agreed to provide the minutes from the HIMT and governing board meetings at which the 6/1/21 policy changes had been discussed and approved, however, no such minutes were provided for the surveyor to review.

In an interview with the Associate Director of Quality, Staff #2, on the afternoon of 6/8/21 in the hospital conference room, she discussed the development of the policy to no longer require masks for visitors and most staff. She stated, "the HIMT committee has dissolved now. Our last meeting was on 3/22/21." She identified HIMT as being the Hospital Incident Management Team. When asked specifically how the policy was written and who approved it, she stated that the CEO and CNO "spoke with the representative of this area and they decided to implement the change. It didn't go through any kind of governing body approval ... As far as I know, it was just done by the two of them ..."


B. The governing body failed to ensure that the hospital followed current nationally accepted standards of practice such as the CDC (Centers for Disease Control & Prevention) infection control guidelines:

Refer to A0747.

Based on observation, interviews, and review of facility documentation, the Medical Center Hospital failed to failed to follow current professional infection control standards for healthcare facilities related to COVID-19 such as the CDC (Centers for Disease Control & Prevention). This was evidenced by:

(1) Discontinuing the requirement for hospital staff and visitors to wear masks upon entering the building (refer to A0749); and

(2) Discontinuing screening procedures for recent exposure to or symptoms of COVID-19 for all visitors to the hospital (refer to A0749).

These failed practices has the likelihood for exposure of a vulnerable patient population, as well as all staff and visitors, to a potentially deadly disease.

Based on review of facility documentation, staff interviews, and observation, the hospital failed to follow current professional infection control standards related to COVID-19 such as the CDC (Centers for Disease Control & Prevention). This had the likelihood to negatively impact the health of all hospitalized patients - a vulnerable population - as well as the health of hospital staff and visitors, through the exposing to a potentially deadly virus.

Findings were:

"Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19 Vaccinations," updated April 27, 2021 (available at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-after-vaccination.html), the current CDC guidelines for healthcare facilities, included the following:

"...CDC has updated select healthcare infection prevention and control recommendations in response to COVID-19 vaccination, which are summarized in this guidance ...

- Visitors should be screened and restricted from visiting, regardless of their vaccination status, if they have current SARS-CoV-2 infection, symptoms of COVID-19, or prolonged close contact (within 6 feet of an infected person for a cumulative total of 15 minutes or more over a 24-hour period) with someone with SARS-CoV-2 infection in the prior 14 days or have otherwise met criteria for quarantine ...

- Visitors, regardless of their vaccination status, should wear a well-fitting cloth mask, facemask, or respirator (N95 or a respirator approved under standards used in other countries that are similar to NIOSH-approved N95 filtering facepiece respirators) for source control, except as described in the scenarios below ...


Physical distancing and source control recommendations when both the patient/resident and all of their visitors are fully vaccinated:

- While alone in the patient/resident's room or the designated visitation room, patients/residents and their visitor(s) can choose to have close contact (including touch) and to not wear source control.

- Visitors should wear source control and physically distance from other healthcare personnel and other patients/residents/visitors that are not part of their group at all other times while in the facility.


Physical distancing and source control recommendations when either the patient/resident or any of their visitors are not fully vaccinated:

- The safest approach is for everyone to maintain physical distancing and to wear source control. However, if the patient/resident is fully vaccinated, they can choose to have close contact (including touch) with their unvaccinated visitor(s) while both continue to wear well-fitting source control ...

Healthcare Personnel
- In general, fully vaccinated HCP (healthcare personnel) should continue to wear source control while at work. However, fully vaccinated HCP could dine and socialize together in break rooms and conduct in-person meetings without source control or physical distancing. If unvaccinated HCP are present, everyone should wear source control and unvaccinated HCP should physically distance from others ...

Healthcare settings refers to places where healthcare is delivered and includes, but is not limited to, acute care facilities ..."


Medical Center Hospital policy entitled "COVID-19 Patient Visitation Policies," updated 6/01/2021, included the following:

The policy listed three hospital entrances and the hours they were unlocked. The remainder of the policy read as follows:

"Visitation Guidelines:

- Non COVID patients (including isolation) can have:

- Two visitors (must be over the age of 16) at a time.

- Comfort Care/End of Life/Hospice: up to 5 visitors at a time.

- Visitors are allowed to switch out/rotate as needed.


- COVID patients (positive or investigation):

- Must wear appropriate PPE and check in at the nurses' station prior to entering patient room

- One visitor per patient per day that is pre-arranged with nursing staff

- Comfort Care/End of Life/Hospice: 2 visitors at a time.
-- Allowed to switch out/rotate


Visitor Requirements:

- It is recommended visitors wear a mask covering nose and mouth while in the building.
It is required while in patient rooms or within 6 feet of a patient.

- Visitors encouraged to remain in patient rooms during visitation

- No visitors allowed (into facility) less than 16 yrs. Old, unless approved by director.

- Lobby and waiting rooms are limited to visitors accompanying a patient for a procedure and must wear a mask at all times.

- Anyone with any symptoms of COVID 19 or recently exposed should not enter the facility.


Other Information:
- Clergy/pastor/minister allowed to visit patients anytime.

- Therapy dogs are allowed.

- Volunteers 16 and up are allowed."


The policy included no signature and thus no indication that it had been approved by any responsible hospital staff with the authority to do so.


A review of hospital document entitled, "Universal Mask Policy and FAQs (Frequently Asked Questions)," revised 5/19/21, revealed the following:

" ...Effective June 1, 2021 ...Personnel working in hallways, at the nurses station, nonclinical offices or in nonclinical settings are no longer required to wear a mask unless engaging with a patient or if instructed to do so by Employee Health due to exposure ...
Due to low community positivity rate, high staff vaccination percentage, increased community vaccination rate and overall decrease in staff exposure to COVID 19 MCH is taking steps to safely move toward a state normalcy [sic] ...

We recognize this is a departure from standard infection prevention; however, we find ourselves in extraordinary times and given current circumstances, we believe this deviation from standard policy is warranted ...

Additionally, we will require all employees to self monitor for symptoms concerning COVID-19 infection ..."


On the morning of 6/8/21 at approximately 9:15 a.m., a hospital volunteer (Staff #4) was working at the front information desk along with another volunteer. She was asked if the hospital was still requiring individuals entering the hospital to wear masks. She replied it was not. When asked when this went into effect, she stated, "there was a letter that went out to all the volunteers." She showed the letter to surveyors and said that it had been sent out in late May and was effective June 1st. When asked if they were still asking individuals entering the hospital screening questions for COVID-19 exposure, she stated, "that all ended on June 1."

While surveyors were waiting at the information desk, at least three staff members walked through the lobby with masks pulled down below their faces. These individuals were identified as staff based on their wearing scrubs and hospital badges. In addition, 2 individuals were noted to enter the building with no masks at all. These individuals were not wearing scrubs and did not have hospital badges. No one at the information desk or hospital entrance asked COVID-19 screening questions of the 2 individuals.


In an interview with the Chief Nursing Officer (CNO), Staff #6, on the morning of 6/8/21 at approximately 9:42 a.m., in the hospital conference room, the CNO stated, "We determined [we could not require masks based] off our community numbers and hospitalizations. They've been going steadily down. Our CEO decided we're going to encourage people to wear masks, but obviously there are people who don't wear masks ... We're requiring healthcare personnel to wear masks when they're working with COVID patients and whenever they're in the patient's room. We're really pushing that visitors wear masks when they're in the patient rooms ..." When asked if they would ask a visitor without a mask to leave the facility, she stated, "No ..." She added, "Prior to this change, we screened visitors and checked temperatures, then we moved forward in our progression towards normal, and have now asked them to self-monitor ..." She confirmed that the changes went into effect on 6/1/21.


In an interview with the Director of Infection Control & Prevention, Staff #5, on the morning of 6/8/21 at approximately 10:00 a.m., in the hospital conference room, she said she had been in her current position since December 2017.

She described the decision-making process to discontinue requirements for visitors and staff to wear masks. "We have a committee - our exposure committee. We had been meeting and discussing it for several months now..." She added, "the decision was that we recommended the staff use masks, but they could take them off in certain situations. Personnel had complained about wearing the masks because of the irritation to the ears and face... We decided to have it be okay not to wear masks unless the staff is doing direct patient care. We'd continue to recommend wearing masks ... And it was so hard to enforce with visitors ... All the changes were effective 6/1/21." When asked if that's when screening visitors for COVID-19 exposure and symptoms stopped, she said "Yes." She also said, "We were aware of the CDC guidelines, but it was just really hard to police it ..."


When asked who was on the exposure committee, she said that it included "someone from employee health, someone from HR (human resources), the CNO, and other nursing management, as well as others." She also said that the policy changes would have been forwarded to the HIMT (Hospital Incident Management Team) committee and the governing board.


Surveyors requested minutes of the meetings of the governing board, HIMT committee and exposure committee in which the policy changes that went into effect on 6/1/21 were approved. Staff #5 said that she did not have minutes for the exposure committee as it was an informal committee. She agreed to provide the other minutes.


Staff #5 discussed the information booth and the main hospital entrance, saying the hospital is not currently doing any kind of screening there for recent COVID-19 exposure or symptoms. She added that employees are supposed to be self-monitoring.


On the way to tour the emergency department (ED), three individuals who appeared to be hospital visitors and one who appeared to be hospital staff were seen without masks in the surgical waiting area. These individuals were not actively eating or drinking at the time.


On the afternoon of 6/8/21, during a tour of the ED at approximately 12:45 p.m., Clinical Coordinator of the ED, Staff #10, said they had ceased screening patients entering the ED for recent COVID-19 exposure and/or symptoms as of 6/1/21. There was evidence of a station inside the ED entry where he said staff used to do the screening but stated that had ended 6/1/21. He then went on to say screening still occurred, but it was not performed at the entry to the ED. "It's just done a few feet further inside ..."

While in the ED, 2 of 3 patients were noted to be in the waiting area not wearing masks.