HospitalInspections.org

Based on observations, interview, and record reviews, the facility's governing body failed to maintain quality patient care when,

- A protocol of placing plastic bags over patient's head and torso was implemented without the Medical Executive Committee or the Governing Body's oversight. This protocol placed patients at risk of hypoxia and asphyxiation. Refer to A0144

- The Governing Body failed to correct the Electronic Medical System from documenting incorrect vital signs and providing incorrect CDC guidelines, placing patients, families and the general public at risk of contracting the virus. Refer to A0438

- The facility did not post the required Emergency Medical Treatments signage, preventing a patient from seeking medical care. The facility did not provide Patient's Rights information, prior to treatment, preventing the patient from making an informed decision. Refer to A0116

Based on observation, interviews, and record reviews, the facility failed to protect and promote each patient's rights to receive respectful care in a safe setting when:

- The facility's practice of placing a plastic bag over Covid positive patient's head and torso placed them at risk of hypoxia and asphyxiation. Refer to A0144

- The facility's EMR (electronic medical record system) recorded abnormal discharge vital signs for a patient and the staff did not correct the vital signs or contact the physician. This places patients at risk of an inappropriate discharge and/or treatment. Refer to A0438

- Discharged patients were given incorrect information regarding the use of face masks; they were informed the CDC recommended not wearing face masks if they are not sick, placing patients, families and the general public at risk of contracting or spreading the virus. Refer to A0116

Based on observation and interview, the facility did not provide the required,

- Emergency Medical Treatments signage, possibly preventing a patient from seeking medical care.

- Patient's Rights information, prior to treatment, preventing the patient from making an informed decision.

Findings include:

Observations made on morning of 10/19/21, of the facility's main entrance lobby and the Emergency Room waiting area, revealed missing postings to inform patients of their right to receive Emergency Medical Treatments. The Emergency room and entrance lobby did not have Patient's Rights postings, which includes, the right to refuse treatments, and how or to whom to voice complaints.

Staff #1, Quality Director, confirmed there were no postings for the EMTALA or the Patient's Rights.

Based on observation, interviews, and record reviews, the facility failed to protect a patient's right to receive respectful care in a safe setting when,

a.) The facility's practice of placing a plastic bag over Covid positive patient's head and torso placed them at risk of hypoxia and asphyxiation.

b.) The facility's EMR (electronic medical record system) recorded abnormal discharge vital signs for a patient and the staff did not correct the vital signs or contact the physician. This places patients at risk of an inappropriate discharge and/or treatment.

c.) Discharged patients were given incorrect information regarding the use of face masks; they were informed the CDC recommended not wearing face masks if they are not sick, placing patients, families and the general public at risk of contracting or spreading the virus.

Findings Include:

a.) Review of the facility provided Protocol, (Undated and not reviewed) reflected, "lntra-facility [sic] Transport of PUI/COVID patient transport Guideline

Purpose: To reduce unintentional facility exposure related to the large amount of viral shedding that occurs with each breath related to COVID-19 patients during transport.

Process: All PUls and COVlD positive patients must wear an isolation drape for all transports outside of their room' Patients that meet criteria for the isolation drape must be alert and oriented. The patient can refuse the isolation drape but must wear a surgical mask at minimum. Transportation staff must wear Airborne PPE plus protective eyewear for transportation. patients must never be left unattended while in the isolation drape' Transportation staff must consist of one licensed staff member at minimum. Patients not alert and/or oriented that require transport must wear a surgical mask during transport.

scripting: ln order to protect patients and staff from acquiring coronavirus we require that you wear a transportation drape for transport to and from your room. This process ensures the safety of other patients and staff members.

Non intubated patient

o Must be alert & oriented

o Patient must be on Nasal Cannula at minimum

o Place surgical mask on patient

o Place isolation drape over patient's head to mid torso. Ensure drape is loose fitting to mid torso intubated patient

o Lay isolation drape over patient's head to mid torso

Ensure circuit is under isolation drape" (An attached photo on the Protocol displayed a female sitting with a loose plastic over a head band; the plastic was not touching the patient's head.)


Review of an Odessa News West 9 television report shows a female, Patient #6, sitting in a wheelchair with a blue face mask covering her mouth. The patient also has an opaque plastic bag sitting on her head and forehead, extending over her arms and torso. She appears to be holding rolled up oxygen tubing in her hand. "EQUIPMENT COVER" was written across the bag directly over patient's face, covering the eyes and nose.


On the morning of 10/18/21, during a telephone interview, Patient #6's mother stated, "I posted the picture on Facebook, I didn't know what else to do. My daughter couldn't breathe, they didn't hook up her oxygen, I had to turn it on. I complained about the bag and was told she had to wear it, it was the policy. She had it on for 30 minutes ..."


During a follow-up telephone interview on the morning of 10/23/21, when asked if a staff member stayed with her daughter while she was under the bag, Patient #6's mother stated, "No, it was just me." When asked if two staff members assisted with transporting her daughter to the ICU, Patient #6's mother stated, "No, just the nurse."


On the morning of 10/19/21, in the administration office, Staff #3, CEO stated, "We became aware of the concern on social media post ...The patients are all on oxygen. They can remove the drape if they need to ..."


During an interview on 10/19/21 at 12:00 pm, in the facility's Emergency Department (ED), when asked if the facility is currently using the equipment bags on patients, Staff #8, ED Director showed the surveyor the location of the equipment bags and stated, "Yes." When asked if she had been involved in the decision to use the bags, staff #8 stated, "No." When asked for the equipment bag manufacturer's provided instructions on the use of the bags on patients, Staff #8 stated, "We looked in the box there wasn't anything in there."


During an interview on 10/19/21 at 12:00 pm, in the facility's ED, Staff #10, ED Educator stated, "The patient has to be oriented, so they can remove the bag if they need to. The patient must be on oxygen, over 6 liters. We give the patients a choice, they can refuse, we document it in the EMAR [electronic medical record]. They can't be left alone and there has to be 2 people to transport." The surveyor pulled on the thick plastic equipment bag and was unable to tear the bag. Staff #10 confirmed the bag was too thick to easily tear apart.


During an interview on 10/19/21 at 3:00 pm, in the conference room, Staff #2, Director of Patient Safety, when asked when the facility started using the bags on patients and if the Manufacturer agreed it was safe to use on patients, Staff #2 stated, "We started using the bags May of 2020. I didn't check with the manufacturer."


During an interview on 10/19/21 at 11:00 am, in the conference room, when asked if the draping protocol was approved by the Medical Staff or Governing Body, Staff #1, Quality Director stated, "No, it was between the ICU and the ED. The plastic was only used in the ED."


Review of the CDC guideline for transporting Covid 19 positive patients found at https://www.cdc.gov//2019-ncov/hcp/faq.html, reflected, "In general, transport and movement of a patient with suspected or confirmed SARS-CoV-2 infection outside of their room should be limited to medically essential purposes. If being transported outside of the room, such as to radiology, healthcare personnel (HCP) in the receiving area should be notified in advance of transporting the patient. For transport, the patient should wear a facemask or cloth face covering (if tolerated) to contain secretions and their body should be covered with a clean sheet."


Facility provided policy titled "PATIENT'S RIGHTS and Responsibilities" (last revised 01/2016) stated in part, "The patient has a right to ...Care that is considerate and respectful of his or her cultural psychological, spiritual, and personal values, beliefs, preferences' and personal dignity ...The patient has the right to Receive care in a safe setting ..."


b.) Review of Patient #6's Discharge vital signs dated 09/04/2021 reflected a peripheral pulse rate of 134 bpm (beats per minute) and that the patient's oxygen saturation was 90% on one liter/minute.

During an interview 10/20/21 at 10:00 am, in the conference room, Staff #4, Nurse Educator confirmed the findings and stated, "The Cerner computer program is pulling in the last value for that field. She wasn't on oxygen when she was discharged, but it is showing 1 liter per minute. I don't know where it is pulling the 134 bpm from."

Review of Patient#6's medical records dated 09/04/21, did not reflect the facility contacting the physician or providing the patient with oxygen for home use.

Review of the facility provided policy titled "Discharge Planning/Assessment" (last revised 10/19) reflected, "B. A discharge set of vital signs should be taken and documented prior to patient departure. Notify discharging physician if there are any abnormalities."


c.) Review of Patient #6's discharge instructions titled "Patient Education" (dated 9/04/2021) stated in part,
"Understanding Coronavirus Disease 2019 (COVID-19) The CDC advises that you should not wear a facemask if you are not sick"

During an interview on 10/20/21 at 10:00am, in the conference room, Staff #11, CNO confirmed the finding and stated, "That's not right."


Review of the Centers for Disease Control's web site, https://www.cdc.gov/coronavirus/2019-ncov/prevent-getting-sick/about-face-coverings.html, reflected "Updated Oct. 25, 2021

Everyone 2 years of age or older who is not fully vaccinated should wear a mask in indoor public places.
In general, you do not need to wear a mask in outdoor settings.

In areas with high numbers of COVID-19 cases, consider wearing a mask in crowded outdoor settings and for activities with close contact with others who are not fully vaccinated.

People who have a condition or are taking medications that weaken their immune system may not be fully protected even if they are fully vaccinated. They should continue to take all precautions recommended for unvaccinated people, including wearing a well-fitted mask, until advised otherwise by their healthcare provider.

If you are fully vaccinated, to maximize protection from the Delta variant and prevent possibly spreading it to others, wear a mask indoors in public if you are in an area of substantial or high transmission ..."