HospitalInspections.org

Based on observation, interview and record review, the facility failed to ensure the reassessment of pharmacological interventions as outlined per hospital policy.

The facility failed to ensure nursing staff reassessed pain effectiveness in one (1) out of ten (10) patients. (ID #1)

Findings including:

Facility policy titled "Pain Management," dated 2/5/21, showed the following information:
V. Procedure
A. When possible pain is assessed using the pain assessment tool:
a. Upon admission/transfer;
b. At shift assessment;
c. Upon report of the onset of new or different pain;
d. Upon change in condition, when appropriate;
e. Prior to any intervention for pain;
f. Within one hour after administration of a medication indicated for pain or other pain-related
intervention


Record review on 4/7/22 of the medical administrative record (MAR) for Patient (ID#1) dated 10/29/2019 revealed Morphine 4 mg was given at 6:00 PM intravenously for a pain score of seven (7). A pain re-assessment was not completed for effectiveness. The patient was discharged at 7:25 PM.

Interview on 4/7/22 at 1:54 PM with nurse manager (ID# 56), she stated, reassessments of pain should be completed within one (1) hour after giving any narcotic or pain medication.

Based on observation, interview, and record review, the facility failed to implement an effective infection prevention program to prevent the widespread transmission of COVID-19 was in place in accordance with the CDC guidelines, and failed to follow facility Infection Control During Construction and Renovation Policy. The facility failed to:

1. implement and monitor their COVID-19 screening process at hospital entrances and ensure staff wore required personal protective equipment (PPE) in public locations where contact with patients and family members exists;

2. follow facility policy on Infection Control During Construction and Renovation


Findings:

1. COVID -19 screening process/source control:


CDC guidance :

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic"
Updated Feb. 2, 2022.

1. Recommended routine infection prevention and control (IPC) practices during the COVID-19 pandemic:

Encourage everyone to remain up to date with all recommended COVID-19 vaccine doses.

Establish a Process to Identify and Manage Individuals with Suspected or Confirmed SARS-CoV-2 Infection

Ensure everyone is aware of recommended IPC practices in the facility.
Post visual alert (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) with instructions about current IPC recommendations (e.g., when to use source control and perform hand hygiene). Dating these alerts can help ensure people know that they reflect current recommendations.

Establish a process to identify anyone entering the facility, regardless of their vaccination status, who has any of the following three criteria so that they can be properly managed:

1) a positive viral test for SARS-CoV-2,
2) symptoms of COVID-19, or
3) close contact with someone with SARS-CoV-2 infection (for patients and visitors) or a higher-risk exposure for healthcare personnel (HCP).
Options could include (but are not limited to): individual screening on arrival at the facility; or implementing an electronic monitoring system in which individuals can self-report any of the above before entering the facility.

Source control and physical distancing (when physical distancing is feasible and will not interfere with provision of care) are recommended for everyone in a healthcare setting.

While it is generally safest to implement universal use of source control for everyone in a healthcare setting, the following allowances could be considered for individuals who are up to date with all recommended COVID-19 vaccine doses (who do not otherwise meet the criteria described above) in healthcare facilities located in counties with low to moderate community transmission. These individuals might choose to continue using source control if they or someone in their household is immunocompromised or at increased risk for severe disease, or if someone in their household is not up to date with all recommended COVID-19 vaccine doses.

HCP who are up to date with all recommended COVID-19 vaccine doses:
Could choose not to wear source control or physically distance when they are in well-defined areas that are restricted from patient access (e.g., staff meeting rooms, kitchen).
They should wear source control when they are in areas of the healthcare facility where they could encounter patients (e.g., hospital cafeteria, common halls/corridors).


Observation on 4/7/22 at 8:35 AM, no screening measures were in place at the entrance to the facility. Staff were observed in the cafe in line, not wearing masks. Upon entrance to Administration, staff (ID 63) did not have a mask on.

Observation on 4/7/22 between 1:45-2:25 PM, showed CNO (ID #51) and Unit Director (ID # 64) at the nurses station and in the hallway not wearing masks.



Review of facility document titled "New COVID-19 Guidelines" from the Office of Executive Vice President (ID# 62) dated 3/31/2022, showed the following information:
As a result of declining community spread of COVID-19, Houston Methodist is loosening its restrictions on visitors, patient testing and masking starting Aril 4.
Visitor Policy and Screening Stations
Houston Methodist is lifting all COVID-19 visitor restrictions...

Houston Methodist screening stations are also being eliminated but we will encourage visitors to wear masks. Each campus can decide if it will make masks available at all entrances.

Employee and Patient Masking Restrictions
Beginning April 4, masks are only required in the following situations:
-Staff and clinical areas such as patient rooms, exam rooms, procedure rooms and diagnostic testing rooms
-Staff closely interacting with patients or prolonged periods outside of clinical areas stated above
-Staff and patients in waiting rooms of doctor's offices or procedure areas
-Staff or volunteers transporting or escorting patients
-Staff working and people getting tested at COVID-19 collection sites
-Staff with vaccination exemption should wear PPE as outlined in the PPE guide
Other Mask Guidelines
-Staff who would like to continue to wear masks may do so
-Employees who work in administrative areas are no longer required to wear masks
-Masks are no longer required in on site meetings and food is allowed
-In Houston Methodist gyms, only staff with vaccination exemptions must wear masks, otherwise they are no longer required

Interview with Chief Nursing Officer (CNO) (ID #51) and Director of Quality (ID #52) on 4/7/22 it was revealed that the facility is no longer screening visitors and staff and that masks are not required in all parts of the hospital. Staff (ID#52) stated that the facility follows CDC guidelines.

When the surveyor requested references used in the decision making process for loosening of COIVID screening and masking requirements an email from the System Infection Preventionist (ID # 60) was provided dated 4/7/22 at 12:01 PM. The email stated: Below is what we discussed related to the CDC guidelines and rationale for the new changes.
The email provided the above current CDC guidelines with the following additional comments:
Implement Source Control Measures: We may need to reconsider masking at the stations/hallways adjacent to patient care areas based on that last line.

System Incident Command considered the following factors when making decisions related to the new changes:
1. Staff vaccination rate is above 99% (including boosters)
2. Exempt employees are required to wear masks at all times and test by PCR weekly.
3. Community indicators show moderate to low values.
4. Houston Methodist indicators show leveling of transmission at a low rate.

Interview with System Infection Preventionist (ID # 60) and System Epidemiologist (ID 61) on 4/7/22 at 2:30 PM, they stated that the screening process is on an honor system, that individuals that had symptoms or concerns would not enter the facility. The recent changes were based on the fact that the numbers are low and that they wanted to provide a sense of relief from this mayhem of a pandemic.


2. Infection Control During Construction and Renovation:

Record review of facility policy titled " Infection Control During Construction and Renovation," dated 7/22/2018 showed the following information:

This policy applies to all contractors, sub-contractors, Facilities Management Services (FMS), Design and Construction, Biomedical, and Information Technology (IT). This policy also applies to any other group, or individuals, performing work which may disturb existing dust or create new dust in the hospitals and clinics.

3.0 Infection Control Risk Assessment (ICRA) Matrix:...

3.1 All class III and above projects and for all projects conducted in risk group 3 or
4 areas, require an approved infection control permit prior to start of the
project.
3.2 Class III projects may require additional risk assessments to be completed.
Consult with Infection Prevention and Control (IP&C) for additional
requirements.

4.0 ICRA Permit Requirements

4.1 The intent of the construction and renovation permitting process is to allow
the infection prevention and control department (IP& C) to assess the risk of
construction, renovation, and routine maintenance activities for patient,
visitors, and employees. During this process the department will specify
infection control preventative measures to be implemented before a project is
started, as well as during the project and at the completion of the work. These
preventative measures are intended for eliminating or minimizing risk of
transmission of opportunistic environmental contaminants to high-risk
individuals.
4.4 The approved infection control permit and any additional risk assessment
documents must be displayed at the entrance to the work area(s) during the
entire construction project. These documents must also be displayed at any
extension of the approved project.
4.5 For projects requiring more than 24 hours for completion and inspection
checklist (i.e., ICRA checklist, CDI) must be displayed at the project site and
must be completed for each working day.

9.0 Quality Control

9.5 On projects which cannot be completed within 24 hours, the contractor is
responsible for conducting daily inspections of the work area in order to ensure
that all infection control preventative measures specified on the permit or
during the risk assessment meeting are in place. Contractor must maintain a
written record of the daily inspection using the ICRA checklist provided by
IP&C. The checklist must be posted outside the project site next to the
infection control permit.

Observation on 4/7/22 at 9:44 AM on the 2nd floor construction area showed an ICRA titled "HMB Bed Tower-Bed Tower Project" with the following information: Project Location-Floor Levels 2 & 3,Start Date 12/8/2020, Completion Date 12/9/2020, Construction Activity Type C:, Infection Control Risk Group 2, Class III. No checklist was observed.

Observation on 4/7/22 at 10:26 AM at the same location revealed construction manager (ID 65) along with infection control personnel (ID #53) removing the ICRA and placing a different one, along with checklist. The newly posted ICRA was titled "HMB Bed Tower- MR level 2" with the following information: Project Location-Floor Level 1-Cardio/Rehab sleep rooms, Start Date 8/7/2020, Completion Date Through Bed Tower Completion, Construction Activity Type D, Infection Control Risk Group 3, Class IV.

Interview with construction manager on 4/7/22 at 10:26 AM, during the above observation, he stated that the wrong ICRA had been in place and he was not sure why there was no checklist posted.

Interview with infection control personnel (ID # 53) on 4/7/22 at 10:28 AM, he stated that he frequently rounds on areas under construction but it is not always documented.