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400 ROSALIND REDFERN GROVER PARKWAY

MIDLAND, TX 79701

INFECTION PREVENTION CONTROL ABX STEWARDSHIP

Tag No.: A0747

Based on observation, interviews, and review of facility documentation, Midland Memorial Hospital failed to meet the Condition of Participation for Infection Control as they failed 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). This was evidenced by:

(1) Discontinuing the requirement for hospital staff and visitors to wear masks if they provided proof of vaccination upon entering the building (refer to A0749); and

(2) Discontinuing screening procedures upon entry into the hospital for visitors and staff if they provided proof of vaccination. (refer to A0749).

These failed practices resulted in the possible exposure of a vulnerable patient population, as well as all staff and visitors, to a potentially deadly disease.


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 such as the CDC (Centers for Disease Control & Prevention) guidelines. 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.

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 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 ..."


Midland Memorial Hospital policy entitled "COVID-19 Temporary Visitation Policy," updated 5/24/2021, included the following:

COVID Patients: The policy provided specific guidelines for visitors on each unit that include visitors who are fully vaccinated and those that are not vaccinated. It also provided information for hospital entrance and hours they were available. The remainder of the policy read as follows:


Other Guidelines Related to Visitation:

-Visitors to the hospital are asked to self-screen for symptoms prior to arrival. You should stay home if you are experiencing illness symptoms (fever, sore throat, cough, or shortness of breath).

- Unvaccinated visitors coming to the hospital will need to have a face covering that goes over their nose and mouth. Visitors who cannot provide proof of vaccination will always be required to wear a face covering while in the building. Any visitor who cannot provide proof of vaccination and refuses and/or is unable to wear a face covering will not be permitted in the building or will be required to leave if already in the building.

-Visitors who are fully vaccinated and can provide proof of vaccination will no longer be required to wear a face covering while in the building. Visitors wishing to use this exemption will need to be banded at the front entrance of the hospital after validation of vaccinated status. Some visitors may still be asked to wear facemasks when visiting patients under isolation precautions or when directed by clinical staff.

- All visitors should perform frequent hand hygiene and restrict their visit to only the patient's room as much as possible.

-Visitors may leave the patient room to get food/refreshments as needed from the Market or Giftshop but should limit this as much as possible. Visitors may also leave the building as needed, but it is strongly encouraged to limit travel as much as possible to lower the risk of disease transmission.

-Congregating in waiting rooms or lobbies is not allowed. Gathering spaces and waiting rooms will remain closed to public use. Large gatherings of people outside of the building will also be discouraged.

-Visitors may be changed or substituted as desired, but no more than 1 visitor will be allowed at one time unless otherwise authorized.

-No children or person under 18 years of age will be permitted at any Midland Health facilities, unless they are here to receive medical treatment or have been emancipated as an adult and are here in a parental/spousal capacity. Extenuating circumstances can be discussed with the Clinical Manager of the unit.

*Support Person is a family member, friend, or other individual who is at the hospital to support the patient during the patient's stay.

Exemptions may be revoked at any time and without notice based on current hospital conditions. Visitor restrictions will be evaluated frequently and updated accordingly.


The policy was approved by the Vice President of Nursing on 05/20/2021. There was no other indication that it had been approved by hospital governing body or other responsible committee.


A review of a hospital email titled to ALL Employees from the CEO, subject titled "Updated: Face Covering Update 5/23/2021" reveled the following:

Consistent with the recent CDC announcement that fully vaccinated people can resume activities without wearing a mask or physically distancing, and that allow governmental entity hospitals to continue to use appropriate policies regarding the wearing of face masks, Midland Health will implement the following updated guidelines, effective Monday, May 24, 2021
Employees, Physicians & Contract staff:

" Individuals who have proof of full vaccination will be allowed to remove their masks in non-patient care areas (breakrooms, meeting areas, hallways, cafeteria, etc.). You are considered fully vaccinated 2 weeks after receiving your 2nd dose of a 2-dose series or 2 weeks after a 1-dose series.

o Employees will need to have the COVID vaccine sticker displayed on their badge.

- If you are fully vaccinated but need a sticker to place on your badge, contact Employee Health and they will provide you a sticker.

- If you would like to receive a vaccine you can call Employee Health at 432-221-1866.

- To find a location to get the COVID-19 vaccine in the community, go to https://midlandhealht.org/main/COVID-19-vaccine-faqs. Be sure to report your vaccine status to Employee Health. (See below)

" Individuals providing direct patient care and/or have direct patient contact will still need to be masked (hospital grade) in all circumstances. If you are interacting with a patient or a visitor (e.g., teaming station, hallway, etc.), you should be wearing a mask.

" Guidelines will be similar to the "Pandemic Flu Plan" policy which will be updated to "Pandemic Respiratory Plan, available in PolicyTech.

" With regard to meetings, meeting organizers may state, "if you have been fully vaccinated and you are comfortable removing your mask, you may do so for the duration of this meeting. You are also free to keep your mask on. For those who have not been fully vaccinated you should keep your mask on during the meeting.


HOW TO REPORT YOUR VACCINATION STATUS TO EMPLOYEE HEALTH

" Individuals who received their vaccines after 5/1/2021 at locations other than MMH Employee Health need to contact Employee Health to document their vaccine status.

" Please e-mail proof of vaccination to crystal.kohanek@midlandhealth.org only. Send a picture of your CDC vaccination card as an attachment rather than in the body of the email. Please include your Employee ID number in the email.

" You can also bring proof of your vaccination to Employee Health. Call 1866 with any questions.

" This information needs to be turned in ASAP, but no later than June 18th.

" If you received your vaccine in Employee Health, you DO NOT need to contact them.


Visitors:

" Visitors will be screened at the front entrance. If the visitor can provide proof of full vaccination, they will be given an arm band and allowed to remove their mask. Visitors who do not have an arm band should keep their masks on.

" The COVID-19 Temporary Visitation Policy is available in Policy Tech and will continue to be revised as appropriate.


Patients:

" All patients with respiratory symptoms need to continue to wear masks.

" COVID positive patients must continue wearing their masks while staff is in their room.


On the morning of 5-25-2021 upon entrance into the hospital, the surveyors were met by staff and asked if we had proof of COVID-19 vaccination. We did not have required proof and thus completed temperature check with hospital screening questions for COVID-19 exposure /symptoms. They informed surveyors to wear a mask at all times while in the hospital. While surveyors were waiting in the hospital entrance area, staff and visitors were observed: some were wearing masks, some were not.

In an interview with the Director of Quality/ Risk Management, staff # 1 on 05/25/2021 in a conference room, she stated, "These new visitation policies began 5-24-2021 and this was communicated via email to all hospital staff on 05/23/2021. She further stated, "The hospital website also has the new visitation information for review." These policies were emailed to surveyors on 06/03/2021:


- COVID-19 Temporary Visitation Policy

- Face Covering Update 5.23.2021

- Pandemic Flu Plan for Midland Memorial Hospital

- Pandemic Plan for Respiratory Diseases at Midland Memorial Hospital


After review of the above documents, an email was sent to the Director of Quality/ Risk Management requesting a phone conference with the hospital to discuss and review.

During the afternoon of June 9, 2021, the CNO and the Director of Quality/ Risk Management participated in a phone interview with surveyor. During the interview the preliminary findings of Complaint TX00384451 were presented.

The facility was provided an opportunity to ask questions. During the interview, The CNO revealed that because of recent other local reviews of changes to visitation and mask requirements, the decision was made to return to masking all visitors, patients, and staff beginning 6-10-2021. The updated policies were emailed for review. He verbalized understanding for the call and follow-up for this complaint.