The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

CHRISTUS GOOD SHEPHERD MEDICAL CENTER- LONGVIEW 700 EAST MARSHALL AVENUE LONGVIEW, TX 75601 Jan. 13, 2016
VIOLATION: QAPI Tag No: A0263
Based on document review and interview, the hospital failed to provide quality oversight for services provided to the hospital by a contracted facility.

The contracted service provided gastrointestinal procedures to hospital patients at an offsite location. Patients were being transferred to this offsite location by hospital employees. The patients received the ordered procedure and were transported back to the hospital by contracted staff. In addition to gastrointestinal procedures being performed at this contracted offsite location, gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. It is not oermissible for other entities to use the hospitals surgical facilities. This contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients.
Refer to tag A0308
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document review and interview, the governing body failed to:

A. provide patient care in a safe setting. Patients admitted to the hospital for acute illnesses were being transferred from the hospital to an Ambulatory Surgical Center (ASC), "a lower level of care," to receive gastrointestinal procedures. This practice posed and immediate jeopardy and placed patients at risk for the likelihood of harm, injury, and even death.
Refer to tag A0144

B. to provide quality oversight for services provided to the hospital by a contracted facility. The contracted service provided gastrointestinal procedures to hospital patients at an offsite location. Patients were being transferred to this offsite location by hospital employees. The patients received the ordered procedure and were transported back to the hospital by contracted staff. In addition to gastrointestinal procedures being performed at this contracted offsite location, gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. This contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients.
Refer to tag A0308

C. develop and implement a process to evaluate contracted nursing staff. Gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. The contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients.
Refer to tag A0398
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on document review and interview, the facility failed to provide patient care in a safe setting. Patients admitted to the hospital for acute illnesses were being transferred from the hospital to an Ambulatory Surgical Center (ASC), "a lower level of care," to receive gastrointestinal procedures.
Refer to tag A0144
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to provide patient care in a safe setting. Patients admitted to the hospital for acute illnesses were being transferred from the hospital to an Ambulatory Surgical Center (ASC), "a lower level of care," to receive gastrointestinal procedures. This practice posed an immediate jeopardy and placed patients at risk for the likelihood of harm, injury, and even death. This immediate jeopardy situation was abated prior to exit.


A review of the definition of an ASC found in the Condition for Coverage at 42 CFR 416.2 revealed Ambulatory Surgical center or ASC means any distinct entity that operates exclusively for the purpose of providing surgical services to patients not requiring hospitalization and in which the expected duration of services would not exceed 24 hours following an admission.


A review of the medical record for patient #1 revealed the patient was admitted on [DATE], with nausea, vomiting, and abdominal pain to the Intensive Care Unit (ICU). Patient had workup including ultrasound of her gallbladder that showed gallstones and then had an abnormal HIDA scan (A hepatobiliary (HIDA) scan is an imaging procedure used to diagnose problems in the liver, gallbladder and bile ducts). Patient had a known cardiac history (low ejection fraction) that was determined her cardiac function was not adequate to allow for cholecystectomy in 11/14.


On 12/18/15, patient was sent to the ASC from the hospital's ICU for an esophagogastroduodenoscopy (EGD). Due to the acute illness requiring hospitalization and the patient's cardiac condition, the risk of transferring the patient to the offsite ASC placed the patient at risk for the likelihood of harm, Injury, or subsequent death. Patient had EGD at ASC on 12/18/15, had inpatient cholecystectomy on 12/20/15, had rapid decline in recovery room with respiratory failure and cardiogenic shock, and expired on [DATE].


A review of patient #2's medical record revealed the patient was admitted on [DATE], for inpatient rehab following a severe left middle cerebral artery stroke. Patient had expressive aphasia with right sided weakness. On 9/3/15, patient was admitted to intermediate care unit due to having an apparent GI (gastrointestinal) bleed as evidenced by syncope, low blood pressure of 109/68, and hemoglobin of 8.1 (done at 2130 on 9/3/15). A GI consult was obtained and orders received to transfuse 2 units of packed red blood cells (PRBC) and hemoglobin to be rechecked the following morning. Hemoglobin was 7.1 at 0200 on 9/4/15 (4.5 hours later). EGD was scheduled at the offsite ASC for 1145 on 9/4/15. Review of ASC consent to treatment revealed it was not signed by the patient and the nurse had written in the reason for patient not signing consent was "patient too ill". The patient was transported to the offsite ASC with an acute GI bleed and the procedure was done.


Interviews were conducted on 1/13/2016, with staff #1, 2, 3, 4, 5, and 6. Staff #1, 2, 3, 4, 5, and 6, confirmed the facility had a contracted service that provided gastrointestinal procedures to hospital patients at an offsite location. Patients were being transferred to this offsite location by hospital employees. The interviews confirmed there was not a screening process to determine if the patients were too ill to leave the confines of the acute care hospital and be transported to the contracted offsite facility. The patients received the ordered procedure and were transported back to the hospital by contracted staff. In addition to gastrointestinal procedures being performed at this contracted offsite location, gastrointestinal procedures were being performed in the hospital's surgical department using contacted staff. This contracted facility would transport equipment from an offsite location to the hospital's surgical department then the contacted staff would assist the physician with the procedure being performed on hospitalized patients. Staff #1, 2, 5, and 6, confirmed there was not a process in place to monitor the contacted services. Staff #1 and #2, confirmed there had not been a process to evaluate the competencies, current required certification and licensing of the contracted employees that had been providing services in the hospital.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on record review and interview, the governing body failed to ensure the quality program provided quality oversight for services provided to the hospital by a contracted facility.

Review of document titled "Gastroenterology Service Agreement" revealed the contracted service provided gastrointestinal procedures to hospital patients at an offsite location. Patients were being transferred to this offsite location by hospital employees. The patients received the ordered procedure and were transported back to the hospital by contracted staff. In addition to gastrointestinal procedures being performed at this contracted offsite location, gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. The contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients.
Interviews on 1/13/2016 with staff #1, 2, 3, 4, 5and staff #6 confirmed the above findings. Staff #1, 2, 5 and staff #6 confirmed there was not a process in place to monitor the contracted services. Staff #1 and #2 confirmed there was not a process to evaluate the employees being provide by the contracted provider.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on record review and interview, the facility failed to develop and implement a process to evaluate contracted nursing staff. Gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. The contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients.
Refer to tag A0398
VIOLATION: SUPERVISION OF CONTRACT STAFF Tag No: A0398
Based on interview, the facility failed to develop and implement a process to evaluate contracted nursing staff. Gastrointestinal procedures were being performed in the hospital's surgical department using contracted staff. The contracted facility (staff) would transport equipment from an offsite location to the hospital's surgical department then the contracted staff would assist the physician with the procedure being performed on hospitalized patients. It is not permissible for other entities to use the surgical facilities of the hospital.

An interview with staff #5 confirmed the above findings. Staff #5 confirmed that the surgical department did not maintain personnel files on the contracted staff that assist the physician with the gastrointestinal procedure being performed on hospitalized patients in the hospital's surgical department.

The facility provided no evidence that the contracted staff was oriented the hospital's policy and procedures. The facility provided no evidence the contracted staff was oriented to the surgical service's policy and procedures. The facility provided no evidence of a process to ensure licensing and certification of the contracted staff was current. The facility did not provide a process to evaluate or establish an expectation of the contracted staffs' skills and competencies.

An interview with staff #1 and staff #2, confirmed there had not been a process established by the nursing department to monitor or evaluate the contracted staff that was assisting the physician in the hospital's surgical department with gastrointestinal procedures.