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 | 700 E MARSHALL AVE LONGVIEW, TX 75601 | Feb. 8, 2021 |
| VIOLATION: INFECTION CONTROL OFFICER RESPONSIBILITIES | Tag No: A0749 | |
| Based on observation, document review, and interview, the facility failed to take measures to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19). Also, the facility failed to follow their own policy. This deficient practice had the likelihood of increased risk of exposure to COVID-19 for patients who were COVID-19 negative upon admission to the facility. Findings included: At the time of the survey the facility had 77 COVID-19 patients and 8 PUI's (patient under investigation). During a tour of the facility with Staff #3 on 02-08-2021 at 10:30 AM observed the following infection control issues: emergency room There were nine staff members in the Emergency nursing station and of those nine, three staff members were not wearing masks. One staff member was observed drinking from a coffee cup with her mask pulled down under the chin. The observation of this issue with no mask went on during the 20-minute tour of the emergency room . Observed six staff members caring for a patient in the trauma room of the emergency room . One of the staff members was only wearing a surgical mask with no N-95 mask. An interview with Staff #7 on 02-08-2021 at 10:30 AM when asked what the requirements were of a staff member on entering a room with a patient Staff #7 stated, "Staff have to wear a N-95 over their mask." There was no signage on the patient doors of the emergency room indicating to other staff members that it was "Strict Droplet Precautions". An interview with Staff #13 (housekeeping) on 02-08-2021 at 1:20 PM was asked how you would know if the patient has isolation precautions. Staff #13 stated, "I look in the trash can to see if there is a blue plastic gown." Surveyor asked were there signs being used in the emergency room to indicate isolation, Staff #13 stated, "no". Immediate Floor A-600 During the tour, observed the door to the 4-bed ward was not completely closed. This ward held four COVID-19 patients. Observed a staff member open the door to the ward and give blood gas report. The staff closed the door and proceeded down the hall leaving the floor and going to the elevator to exit the floor without washing or sanitizing her hands after opening and closing the COVID19 door. Floor S-400 (had 27 COVID-19 patients) During the tour of the floor observed the doors to the COVID 19 rooms were not completely closed. An interview with Staff #3 on 02-08-2021 at 11:30 AM confirmed the above observations during the tour of the facility. A review of the policy titled, "Universal Masking" with a review date of 09/22/20 revealed the following: "CHRISTUS Health follows the guidelines of the Centers for Disease Control (CDC) and provides processes to keep patients, Associates, and clinicians safe from possible transmission of emerging pathogens from the community. As of April 8, 2020, all individuals providing any form of medical care in CHRISTUS ministries are required to wear a medical facemask at all times while in CHRISTUS facilities where patients are housed." A review of the policy titled, "Standard and Transmission based Isolation Precautions" with an effective date of 06/26/20. "These procedures have been developed (in connection with CDC guidelines) to isolate the disease and not the patient. The purpose is to prevent the spread of microorganisms among patients, personnel and visitors as well as provide optimum patient care. (letter F) The appropriate isolation precaution sign must be affixed to the patient's doorway or entryway, in the isolation caddy, or near entrance to patient care." A review of the CDC Guidelines for patients with suspected Coronavirus Disease (COVID-19) revealed the following: "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Update December 14, 2020. Patients should be isolated in an examination room with the door closed. Implement Universal Source Control Measures Source control refers to use of well-fitting cloth masks or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of COVID-19. Patients and visitors should wear their own cloth mask (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth mask Patients may remove their cloth mask when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. Facemasks and cloth masks should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance. Visitors who are not able to wear a cloth mask or facemask should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from SARS-CoV-2 infection. HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth masks should NOT be worn instead of a respirator or facemask if more than source control is needed. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth mask. HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth mask when leaving the facility at the end of their shift. Educate patients, visitors, and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth mask. Implement Universal Use of Personal Protective Equipment 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 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for: Aerosol generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings FAQ) and Surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ) Hand Hygiene HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS." An interview with Staff #3 on 02-08-2021 at 2:00 PM confirmed that facility staff members had failed to follow their own policy and this practice had the likelihood to increase the risk of exposure to COVID-19 for patients who were COVID-19 negative upon admission to the facility. |
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| VIOLATION: IC PROFESSIONAL ADHERENCE TO POLICIES | Tag No: A0776 | |
| **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, document review, and interview, the infection control preventionist failed to ensure the facility's infection control plan to contain and/or prevent the transmission of a highly suspected contagious Coronavirus (COVID-19) was followed by all staff. Also, the infection control preventionist failed to have knowledge of the facility's environmental services (EVS) policy regarding cleaning procedures for COVID-19. This deficient practice had the likelihood to have increased the risk of exposure to COVID-19 for patients and staff. Findings included: The infection control preventionist (Staff #6) failed to ensure the following facility policies were followed by hospital staff: Universal Masking : "CHRISTUS Health follows the guidelines of the Centers for Disease Control (CDC) and provides processes to keep patients, Associates, and clinicians safe from possible transmission of emerging pathogens from the community. As of April 8, 2020, all individuals providing any form of medical care in CHRISTUS ministries are required to wear a medical facemask at all times while in CHRISTUS facilities where patients are housed." Standard and Transmission Based Isolation Precautions: "These procedures have been developed (in connection with CDC guidelines) to isolate the disease and not the patient. The purpose is to prevent the spread of microorganisms among patients, personnel and visitors as well as provide optimum patient care. (letter F) The appropriate isolation precaution sign must be affixed to the patient's doorway or entryway, in the isolation caddy, or near entrance to patient care." CDC Guidelines for patients with suspected Coronavirus Disease (COVID-19): "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Update December 14, 2020: "Interim Infection Prevention and Control Recommendations for Patients with Suspected or Confirmed Coronavirus Disease 2019 (COVID-19) in Healthcare Settings Update December 14, 2020. Patients should be isolated in an examination room with the door closed. Implement Universal Source Control Measures Source control refers to use of well-fitting cloth masks or facemasks to cover a person's mouth and nose to prevent spread of respiratory secretions when they are talking, sneezing, or coughing. Because of the potential for asymptomatic and pre-symptomatic transmission, source control measures are recommended for everyone in a healthcare facility, even if they do not have symptoms of [DIAGNOSES REDACTED] Patients and visitors should wear their own cloth mask (if tolerated) upon arrival to and throughout their stay in the facility. If they do not have a face covering, they should be offered a facemask or cloth mask Patients may remove their cloth mask when in their rooms but should put it back on when around others (e.g., when visitors enter their room) or leaving their room. Facemasks and cloth masks should not be placed on young children under age 2, anyone who has trouble breathing, or anyone who is unconscious, incapacitated or otherwise unable to remove the mask without assistance. Visitors who are not able to wear a cloth mask or facemask should be encouraged to use alternatives to on-site visits with patients (e.g., telephone or internet communication), particularly if the patient is at increased risk for severe illness from [DIAGNOSES REDACTED]-CoV-2 infection. HCP should wear a facemask at all times while they are in the healthcare facility, including in breakrooms or other spaces where they might encounter co-workers. When available, facemasks are preferred over cloth face masks for HCP as facemasks offer both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others. Cloth masks should NOT be worn instead of a respirator or facemask if more than source control is needed. To reduce the number of times HCP must touch their face and potential risk for self-contamination, HCP should consider continuing to wear the same respirator or facemask (extended use) throughout their entire work shift, instead of intermittently switching back to their cloth mask. HCP should remove their respirator or facemask, perform hand hygiene, and put on their cloth mask when leaving the facility at the end of their shift. Educate patients, visitors, and HCP about the importance of performing hand hygiene immediately before and after any contact with their facemask or cloth mask. Implement Universal Use of Personal Protective Equipment HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. If [DIAGNOSES REDACTED]-CoV-2 infection is not suspected in a patient presenting for care (based on symptom and exposure history), HCP should follow Standard Precautions (and Transmission-Based Precautions if required based on the suspected diagnosis). They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Wear an N95 or equivalent or higher-level respirator, instead of a facemask, for: Aerosol generating procedures (refer to Which procedures are considered aerosol generating procedures in healthcare settings FAQ) and Surgical procedures that might pose higher risk for transmission if the patient has COVID-19 (e.g., that generate potentially infectious aerosols or involving anatomic regions where viral loads might be higher, such as the nose and throat, oropharynx, respiratory tract) (refer to Surgical FAQ) Hand Hygiene HCP should perform hand hygiene before and after all patient contact, contact with potentially infectious material, and before putting on and after removing PPE, including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. HCP should perform hand hygiene by using ABHS with 60-95% alcohol or washing hands with soap and water for at least 20 seconds. If hands are visibly soiled, use soap and water before returning to ABHS." At the time of the survey this facility had 77 COVID-19 patients and 8 PUI 's (patient under investigation). During a tour of the facility with Staff #3 on 02-08-2021 at 10:30 AM observed the following infection control issues: emergency room There were nine staff members in the Emergency nursing station and of those nine, three staff members were not wearing masks. One staff member was observed drinking from a coffee cup with her mask pulled down under the chin. The observation of this issue with no mask went on during a 20-minute tour of the emergency room . Observed six staff members caring for a patient in the trauma room of the emergency room . One of the staff members was only wearing a surgical mask with no N-95 mask. An interview with Staff #7 on 02-08-2021 at 10:30 AM when asked what the requirements were of a staff member on entering a room with a patient. Staff #7 stated, "Staff have to wear a N-95 over their mask." There was no signage on the patient doors of the emergency room indicating to other staff members that it was "Strict Droplet Precautions." An interview with Staff #13 (housekeeping) on 02-08-2021 at 1:20 PM was asked how you would know if the patient has isolation precautions. Staff #13 stated, "I look in the trash can to see if there is a blue plastic gown." Surveyor asked were there signs being used in the emergency room to indicate isolation. Staff #13 stated, "No." Immediate Floor A-600 During the tour observed the door to the 4-bed ward was not completely closed. This ward held four COVID-19 patients. Observed a staff member open the door to the ward and give blood gas report. The staff closed the door and proceeded down the hall leaving the floor and going to the elevator to exit the floor without washing or sanitizing her hands after opening and closing the COVID19 door. Floor S-400 (had 27 COVID-19 patients) During the tour of the floor observed the doors to the COVID 19 rooms were not completely closed. An interview with Staff #3 on 02-08-2021 at 11:30 AM confirmed the above observations during the tour of the facility. An interview Staff # 6 was conducted on 02-08-21 at 1:45 PM. Staff # 6 was asked how housekeeping staff were to identify positive or suspected positive COVID-19 patient rooms in the ER; due to isolation patients were not being identified with door signage. Staff # 6 stated, "All patients in the ER were treated as if they had COVID-19." Staff # 6 was asked if housekeeping should be using their two-step cleaning process as outlined in the EVS policy titled, "Coronavirus (COVID-19) Action Steps." Staff # 6 stated, he was unaware of the 'Coronavirus (COVID-19) Action Steps' policy that was being used to disinfect COVID 19 rooms by the environmental services (EVS) department. A review of the EVS policy titled, "Coronavirus (COVID-19) Action Steps: section #3 Cleaning Procedures for Confirmed COVID-19 Patients Care Rooms.......Clean all potentially infected areas with COVID-19 TWICE." |
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