HospitalInspections.org

Based on observation, interviews, and review of facility documentation, the facility failed to meet the Condition of Participation for Infection Control by failing to follow current professional infection control standards for healthcare facilities related to CoVid-19 as set forth by the CDC (Centers for Disease Control & Prevention).

As evidenced by:

(1) Discontinuing the requirement for hospital staff and visitors to wear masks upon entering the building (please refer to A0748).

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

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)

"...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 ..."


The following observations were made at the facility on 07/13/2021:

* A surveyor (#1) arrived at the facility at 09:15 AM on 07/13/21, upon entering the building noted no staff members or visitors at the facility had masks. There was no signage outside to indicated masks were required in the facility.

* Surveyor #1 was screened for temperature but not asked to complete a "Covid-19 Assessment Tool" when entering the facility.

* Surveyor #1 asked why staff were not wearing masks, especially in patient care areas. Staff member #1 , stated, "we've had different guidance from the CDC (Centers for Disease Control)" and indicated masks were not required at the facility.

* Two other surveyors #2 and 3, entered the facility to assist in an EMTALA survey at approximately 10:30 AM. Both surveyors also noted no visitors or the security guard providing screening in the front area of the facility were wearing masks. Both surveyors were only screened for temperature and not asked complete a "Covid 19 Assessment Tool" when entering the facility.

* Several member of the administration team were noted to be not wearing masks upon making introductions to the surveyors. Some of the administrative team members included the CEO, Risk Manager, and Emergency Department Director, who were all observed without masks on.


The facility was notified on 07/13/2021 at approximately 11:30 AM that there was a possible immediate jeopardy at the facility related to infection control due to CDC recommendations remain in place for healthcare personnel and visitors in healthcare facilities to continue wearing masks. Staff members #2 and 3, entered the conference room stating that they had CDC guidance documents that if their community is low risk with Covid cases, they do not have to wear mask. They stated mask mandate changes were initiated after communicating with the local health department about status of the community being a low risk profile thus wearing masks for staff and visitors were not required. The facility was asked for copies of this information.


Staff member # 2 stated that if their understanding was wrong they would be happy to correct the issues and re-instate masks in order to be in compliance with CDC ands CMS guidance.


The following information was provided by staff member #3, Director of Infection Prevention, to support their decision to discontinue mask use at the facility. See attachment: Facility CDC Information. A print out of paper work that stated in part,

"Summary of CDC Guidance ...

B. Updated Healthcare Infection Prevention and Control Recommendations in Response to COVID-19

Vaccination Updated Apr. 27, 2021

o Updated SARS-CoV-2 testing recommendations

o Updated visitation guidance to include recommendations for acute care facilities and to describe circumstances when source control and physical distancing are not required during visitation

o Added guidance for communal activities and dining in healthcare settings

Acute care facilities:

1. Visitation should continue to be prioritized for those visitors important for the patient's physical or emotional well-being and care (e.g., care partner, parents).

5. Use of Personal Protective Equipment
o Recommendations for use of personal protective equipment by HCP remain unchanged.

C. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVTD-19) Pandemic Updated Feb. 23, 2021

o For guidance on recommended source control for HCP, refer to Implement Universal Use of Personal
Protective Equipment below.

o HCP should wear well-fitting source control at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers.

o To reduce the number of times HCP must touch their face and potential risk for self-contamination, when used for source control, HCP should consider continuing to wear the same respirator or well-fitting facemask (extended use) throughout their entire work shift.

o HCP should remove their respirator or facemask, perform hand hygiene, and put on their community source control when leaving the facility at the end of their shift.

HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with SARS-CoV-2 infection. If SARS-CoV-2 if infection is not suspected in a patient presenting for care (based on symptom and exposure history): ...

HCP working in areas with minimal to no community transmission, should continue to adhere to Standard and Transmission-Based Precautions based on anticipated exposures and suspected or confirmed diagnoses. This might include use of eye protection, an N95 or equivalent or higher-level respirator, as well as other personal protective equipment (PPE). In addition. universal use of a well-fitting facemask for source control is recommended for HCP if not otherwise wearing respirator."


During a tour of the Emergency Department on 07/13/21 at 1:10 PM, both surveyors # 1 and 2, observed at least 5 staff members in scrubs were in the common hallways with no mask or face coverings present.

On the walk back form the ED, staff member #1 , verified that the facility policy to not require staff to wear masks occurred in the past few months and there was no policy to address the practice change. She stated, "I'm not sure when, there was an email I think about it".

* At approximately 1:35 PM on 07/13/21, an overhead announcement was made that staff were required to wear allocated masks effective immediately. After that announcement all staff members observed by the surveyors had masks on per CDC guidelines.

* After this announcement posted signage was noted at the hospital entrance that masks were required at the facility.

* At 2:02 PM on 07/13/21, the facility CEO was emailed an IJ template covering the identified infection control immediate jeopardy of not wearing face masks at the facility per CDC guidelines


In an interview on 07/13/2021 at 2:30 PM, with staff member #3, they were asked when the facility stopped requiring staff to wear masks. They replied, "we continued to tell them we highly recommend masks. When the governor made his whole spill and visitors came in and they were highly aggressive. I had already been beat up for about year by visitors. After we vaccinated the majority of our clinical staff the push back was big. When CDC guidance came in about low transmission rate, my general response was masks are highly recommended for vaccinated and unvaccinated and did that in reply to the requests [to not wear masks]...We continue to follow standard and transmission based precautions the whole time."

Staff member #3 was asked when staff were informed that they no longer needed to wear masks. Staff member #3 replied, "the email went out in March, about May was when the last visitation update went out. We were more lax with no Covid cases here for a couple of months. In June, we had a health department meeting, with low community transmission rate and did data for the whole communication around June 6th."

Staff member #1 added that the decision to not have staff or visitors wear masks, "went to the MEC (Medical Executive Committee) and there was vote with the C-suite, but there was no official meeting."

Facility based policy entitled, "Visitation" PolicyStat ID: 6048893 stated in part,

"COVID-19 Precautions:

Lubbock Heart & Surgical Hospital has complied with and enforced mitigation strategies throughout the COVID-19 pandemic. We recognize that COVID-19 will not go away and some of our processes we have put into place to help mitigate the risk of exposure in the facility will continue.

The processes/procedure put into place that will continue are as follows:

A. Face coverings are being evaluated daily and ALL individuals who enter any of our entities will be asked to continue to wear face coverings.

1. We will respect each individuals rights to refuse the use of a daily mask and will not engage in confrontation.

a. Example: If a patient comes into the building for their procedure and refuses to wear the mask. We will not refuse care or admission to any individuals and will not engage in confrontation with them. Simply put, we respect their decision.

2. Patients, visitors, vendors etc will continue to be asked to bring their own face covering for use while in our facilities.

3. Employees will be required to follow all isolation guidelines.

a. You must ONLY wear hospital approved/provided PPE in ALL isolation rooms per policy and procedure. You must remove your (personal) mask prior to entering an isolation room and put on hospital provided PPE.

b. Your personal mask is NOT to be worn under or over N95 mask when caring for patients with airborne precautions. You can however cover you N95 with a surgical mask provided by the hospital.

c. NO MASKS are to be worn under the PAPR hood at any time even during surgery.

d. Isolation patients including suspected or confirmed COVID-19 patients: Visitation is limited to two visitors at a time who are essential to the patient's care. If visitation is allowed, the visitor should remain in the room and wear appropriate PPE.

Please Note:

i. Non-hospital provided face masks have not been reviewed/fitted for optimal protection, safety or effectiveness in protection from infection.

ii. Non-hospital provided N-95s have not met Fit Testing requirements and may give a false sense of security and will not be used on any one under isolation.

iii. Hospital is in conventional level on PPE, meaning to utilize PPE in the same manner you did prior to pandemic. See attachment"