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.

MEMORIAL HERMANN HOSPITAL SYSTEM 1635 NORTH LOOP WEST HOUSTON, TX 77008 Nov. 11, 2020
VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES Tag No: A0749
Based on observation, interview, and record review, the facility failed to fully implement a COVID-19 screening process for employees, visitors, and vendors per CDC guidelines and facility policy.

Two (2) of 2 screeners allowed visitors entry into the facility without asking COVID screening questions or requesting completion of a questionnaire;

Two (2) of 2 screeners did not have validated COVID-19 screening competencies per facility policy.

This deficient practice could contribute to widespread transmission of COVID-19 within the facility.

Findings included:

COVID-19 screening: employees, visitors, and vendors:

Record review of CDC "Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic,"updated July 15, 2020, recommended "...Screen everyone (patients, HCP, visitors) entering the healthcare facility for symptoms consistent with COVID-19 or exposure to others with SARS-CoV-2 infection and ensure they are practicing source control. Actively take their temperature and document absence of symptoms consistent with COVID-19. Fever is either measured temperature =100.0F or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARS-CoV-2 infection...."

Record review of facility Standard Operating Procedures titled "COVID-19 Employee / Physician / Visitor / Vendor/ Contractor: Entry Point Screening Stations,"undated, showed:

* Screeners should have validated competency.
* Screener takes temperature or asks individual to walk through thermal scanner.
* There is a reference in the procedure to a paper questionnaire: " visitor. ..questionnaires should be shredded at the end of the day..." The facility COVID screening procedure did not state that visitors must complete this questionnaire or be asked the questions verbally by the screener.

Review of facility form "Patient/ Visitor Screening Questionnaire," undated, showed questions:

1. Fever in last 24 hours (greater that 100.1 F)?
2. Recent onset of loss of taste/smell?
3. Any of the following symptoms ( recently) :coughing (not allergy); nasal congestion ( not allergy); sore throat; shortness of breath; diarrhea, nausea/vomiting; fatigue
4. Personal COVID-19 exposure?
5. Have you tested positive for COVID-19 in the last 14 days?

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Observation # 1:

Observation at the front entrance on 11/09/2020 at 8:45 A.M. showed a hand sanitizing station , a thermal temperature scanner on a pole; and a table with a staff person stationed there (Screener #1). Screener # 1 instructed surveyor where to stand in order to have a thermal temperature scan. Screener # 1 then took out a paper band to place on surveyor's wrist. This surveyor stood there for a few minutes, waiting for COVID screening questions to be asked. Screener # 1 failed to ask any screening questions or request surveyor to complete a written questionnaire.

Observation # 2 :

Observation at the front entrance on 11/09/2020 at 10:15 A.M. showed a hand sanitizing station , a thermal temperature scanner on a pole; and a table with a staff person stationed there (Screener #2). Observation showed Screener # 2 used a "no- touch infrared" thermometer to measure the temperature of four(4) different visitors. Screener # 2 failed to ask any of the four (4) visitors screening questions or request completion of a written questionnaire. She allowed all four (4) visitors entry into the facility with only a temperature measurement.

On 11/10/2020, surveyor requested the training and competencies for COVID-19 Screeners # 1 and 2.

During an interview on 11/10/2020 at 11 A.M. with Staff E, she stated the facility had previously conducted "Just In Time" training for the screeners. The validated competency training began in September 2020. She said the facility was still trying to get all the screeners formally trained. Screener # 1 and Screener # 2 did not have validated competencies for COVID 19 screening.