Christus Mother Frances Hospital Sulphur Springs

“SAFETY FOR PATIENTS AND PERSONNEL CFR(s): 482.26(b)(1) Proper safety precautions must be maintained against radiation hazards. This includes adequate shielding for patients, personnel, and facilities, as well as appropriate storage, use and disposal of radioactive materials. This Standard is not met as evidenced by: 48749 Based on observation, document review, and interview, the hospital failed to ensure the safe and secure storage of radioactive dye (Intravenous Contrast) in 2 of 2 Computed Tomography (CT) rooms in the Radiology Department. The hospital failed to follow its “Contrast Agents-Handling and Storage” policy. Findings include: A tour was conducted in the Radiology Department on 11/10/2025 at 10:25 AM with Staff #4 and Staff #7. In CT Room #1 (Next to the ED), it was observed that single-dose and multidose intravenous (IV) contrast dye bottles were stored in a standalone cabinet next to the door of the room. The cabinet was observed to be unsecured, the room was unattended, and the door to the CT room was propped open. This had the potential of allowing any unauthorized staff, patients or visitors to have access to radioactive contrast agents. In CT Room #2 (Next to the Chapel), it was observed that single-dose and multidose IV contrast bottles were stored in a cabinet on the wall. The cabinet was observed to be unsecured. A review of the hospital’s “Contrast Agents-Handling and Storage” policy dated 06/2024 revealed the following: “GUIDELINE STATEMENT: Personnel will adhere to manufacturer’s recommendations for proper handling and storage of contrast agents throughout the Radiology Department. B. Storage/ Control General Stores maintain some stock of Oral Contrast. Pharmacy keeps a PAR level of IV contrast and Gadolinium. Oral, IV, and Gadolinium in the radiology department are kept locked or in restricted areas. Contrast in the General Stores is limited to access by authorized personnel. General Stores is a restricted (locked) area.” An interview was conducted with Staff #4 on 11/10/2025 at 10:40 AM. Staff #7 reported that IV contrast agents are to remain locked up at all times. Staff #4 and Staff #7 confirmed the surveyor’s findings of unsecured IV contrast agents in the Radiology Department.”

“INFECTION CONTROL SURVEILLANCE, PREVENTION CFR(s): The infection prevention and control program includes surveillance, prevention, and control of HAIs, including maintaining a clean and sanitary environment to avoid sources and transmission of infection, and addresses any infection control issues identified by public health authorities; and This Standard is not met as evidenced by: 48653 Based on observation, record review, and staff interviews, the hospital’s infection control and prevention program failed to provide and maintain a sanitary environment to avoid sources of transmission of infections in 2 (Emergency Department and Radiology Department) of 2 departments of the hospital. The hospital failed to follow the “Infection Prevention and Control Plan” policy. Findings include: During a tour of the hospital on 11/10/2025 at 10:30 AM with Staff # 3 and # 4 the following infection control issues were identified: Emergency Department *There was a red cart on wheels labeled “Treatment Cart” that had a thick layer of dust and dirt. The dust was collecting on top of sterile patient supplies. The second and third shelves of the cart had large clumps of dust and dirt collecting on the inside of the cart and the patient supplies. *The medication room had a build-up of dust inside the cabinets, which contained sterile patient supplies such as intravenous needles and lab collection tubes. Radiology Department *The emergency code cart inside of the CT room, located across the hall from the chapel, was covered in a thick layer of dust and dirt buildup. The dust and dirt were on the top of the emergency code cart and the top of the defibrillator. *There was an intravenous contrast bottle and an intravenous saline bag hanging from an IV (intravenous) pole next to the CT scanner located across the hall from the chapel. The bag of IV saline was labeled “11/07 2155”. The surveyor asked Staff # 7 (Radiology Director) when the IV bag and associated tubing expired. Staff # 7 replied, “It is only good for 12 hours”. *There was a metal storage rack inside the CT scanner room, located across the hall from the chapel. The metal rack was used to store 150 ml (milliliter) Sterile Disposable Syringes with Spikes. The bottom shelf of the metal rack did not contain a clear plastic liner to prevent any dust, dirt, cleaning liquids, etc. from coming into contact with the sterile patient supplies stored on the bottom shelf. A review of the hospital’s “Infection Prevention and Control Plan” policy with a date of 07/25 revealed, “ ...The following responsibilities and authorities apply to Infection Prevention departments in all CHRISTUS ministries: *Independently identify, report, and analyze the incidence of healthcare-associated infections (HAI) utilizing Center for Disease Control (CDC)/National Healthcare Safety Network (NHSN) HAI surveillance definitions. *Analyze infection data to identify clusters of infections, outbreaks, sentinel events, or emerging pathogens. *Develop and implement a preventive and corrective program designed to minimize infection hazards detected in any clinical setting. *Implement emergency prevention measures if significant infection risk trends are identified. *Facilitate an Infection Prevention and Control Council to educate and standardize prevention practices. *Development and approval of all policies and procedures related to infection surveillance, prevention, and control activities. *Promote the application of enterprise policies relating to infection prevention. *Identification of environmental risks or regulatory deficiencies related to the physical environment of the clinical setting. *Identification of clinical best practices related to prevention of infection and validation of best practice implementation in patient care areas, including ED, outpatient/ambulatory, procedural, surgical, and inpatient settings. *Validation for isolation precautions, barrier precautions, or environmental cultures are required for prevention of infection transmissions. *Infection Prevention has the authority to determine when a higher level of precautions is needed than observed and will communicate these needs when identified. *Infection Prevention must be contacted prior to the removal of airborne precautions to ensure that removal is appropriate and safe. *Collaborate with ministry and enterprise leadership to institute emergency measures to prevent infections. *Participate in multidisciplinary committees, including but not limited to: *Pharmacy and Therapeutics Committee and/or Antimicrobial Stewardship Committee related to antibiotic utilization practice patterns ....Data Collection and Reporting: Data Collection: System-wide surveillance is performed via an electronic infection prevention reporting and tracking system. Notifications are monitored from public health and federal resources. Alerts are reviewed from the Centers for Disease Control for impact to the patient populations. Items identified for action are communicated to the Chief Clinical Officer for discernment on action plans for system-wide impact to mitigate the risk for spread of infection. *Surveillance focuses on high-volume, high risk and problem prone procedures ....” An interview was conducted with Staff # 2, and # 3 on 11/10/2025 at 11:30 AM which confirmed the hospital’s infection control issues in the hospital’s emergency department radiology department.”

“ORGANIZATION AND DIRECTION CFR(s): 482.55(a) Organization and Direction. If emergency services are provided at the hospital -- This Standard is not met as evidenced by: 10135 Based on interview and record review, the facility failed to ensure the Emergency department (ED) was directed in a manner to ensure complete assessments were performed prior to discharging 1 of 23 sampled patients (Patient #6). Staff failed to obtain vital signs on Patient #6 prior to discharge. This deficient practice had the likelihood to affect all patients presenting to the ED. Findings include: Review of the ED record on Patient #6 revealed she was a 90-year-old female who presented to the ED on 12/01/2024 at 11:05 a.m. via ambulance. According to the record the physician’s medical screening exam (MSE) started at 11:05 a.m. Patient #6 presented with complaints of epigastric abdominal pain with gradual worsening in severity for a week. According to the record Patient #6 had diagnoses which included diabetes mellitus Type II, hyperlipidemia, cerebral vascular accident, hypertension, and paroxysmal atrial fibrillation. Patient #6 was triaged at 11:18 a.m. and given an emergency severity index (ESI) level of 3 (meaning urgent). At 11:19 a.m., Patient #6 had a blood pressure of 151/60, heart rate of 60, respiration of 20, temperature of 98.4 degrees Fahrenheit, abdomen pain level of 3 and an oxygen saturation of 100 percent on 3 Liters of oxygen. There was documentation in the assessment of Patient #6 being oxygen dependent at home. At 11:22 a.m., Patient #6 had a blood pressure of 151/60 and a heart rate of 59. Lab reports revealed some of the following: A Pro BNP (indicator of acute heart failure) which was collected at 11:26 a.m. was elevated at 18,800 with reference ranges being 0-300. A urinalysis which was collected at 11:39 a.m. and showed a few white blood cells and many bacteria. At 11:41 a.m., Patient #6 had a blood pressure of 194/118, heart rate of 58, respiration of 18 and an oxygen saturation of 100 percent. At 11:46 a.m., Patient #6 had an oxygen saturation of 100 percent on 3 Liters of oxygen and epigastric pain at a level 8. The results of the chest x-ray signed off at 11:46 a.m., showed no acute abnormality identified, chronic elevation of the left hemidiaphragm with adjacent left basilar atelectasis, normal heart size and prominent calcification of the mitral annulus At 11:48 a.m., Patient #6 had a respiration rate of 16 and a pain level of 8. The pain medication morphine 4 milligrams was administered via intravenous. At 11:49 a.m., Patient #6 had a blood pressure of 196/76, heart rate of 60, respiration of 16, and an oxygen saturation of 99 percent. At 12:04 p.m., Patient Smith had a blood pressure of 159/62, heart rate of 58, respiration of 18 and an oxygen saturation of 94 percent. The computed tomography scan signed off at 12:35 p.m. revealed there was patchy ground glass opacities in the lung bases, small left pleural effusion, diverticulosis without evidence of diverticulitis, and a small fat containing umbilical hernia. At 12:52 p.m. the physician decided to discharge Patient #6 with diagnoses of urinary tract infection and bibasilar pneumonia. Patient #6 was discharged on the antibiotic Doxycycline. A 1:37 p.m., a dose of doxycycline was administered by Staff #9 (Registered nurse). At 1:52 p.m., there was documentation that Patient #6 was stable,on oxygen 3 liters per nasal cannula, without pain and was preparing to be discharged home. The last set of vital signs on Patient #6 were almost 2 hours before discharge. Review of another ED record on Patient #6 returned to the ED via ambulance at 4:27 p.m. on 12/01/2024 in cardiac arrest. During an interview on 12/30/2024 after 1:27 p.m., Staff #4 (ED Director) confirmed there was no documented vitals signs in the chart after 12:04 p.m..Staff #4 (ED Director) said that vital signs were supposed to be obtained within 30 minutes of patients being discharged from the ED. During an interview on 01/03/2024 after 10:30 a.m., Staff #9 (Registered nurse) confirmed that she was the nurse that discharged Patient #6 from the ED on the first visit. Staff #9 (Registered nurse) confirmed she gave Patient #6 a dose of antibiotic prior to discharge. Staff #9 (Registered nurse) said Patient #6 was awake, alert and took her medications without any problems. Patient #6 went home on 3 liters of oxygen. Patient #6 was assisted to the car between 1:53 p.m. and 2:15 p.m. Staff #9 (Registered nurse) checked Patient #6’s chart and confirmed she could not find any documentation of vital signs. She stated they are supposed to take vital signs within 30 minutes of a patient’s discharge. Review of a facility’s policy named “Title: Vital Signs Reassessment in the Emergency Department per ESI” dated 03/2021 revealed the following: “ ...C.ESI level 3: ...4. Vital sign assessment should be current within 30 minutes of discharge ...””

“POSTING OF SIGNS CFR(s): 489.20(q) [The provider agrees,] in the case of a hospital as defined in §489.24(b), to post conspicuously in any emergency department or in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment in areas other than traditional emergency departments (that is, entrance, admitting area, waiting room, treatment area) a sign (in a form specified by the Secretary) specifying the rights of individuals under section 1867 of the Act with respect to examination and treatment for emergency medical conditions and women in labor; and to post conspicuously (in a form specified by the Secretary) information indicating whether or not the hospital or rural primary care hospital (e.g., critical access hospital) participates in the Medicaid program under a State plan approved under Title XIX. This Standard is not met as evidenced by: 10135 Based on observation and interview, the facility failed to ensure the required rights posting with respect to examination and treatment for emergency medical conditions and women in labor was conspicuously posted in 2 of 2 waiting areas in the Emergency Department (ED). This deficient practice had the likelihood to affect all patients presenting to the ED. Findings include: During an observation of the ED on 12/30/2024 after 2:10 p.m., the Main waiting room area was noted to have patients sitting in the area. There were no required rights posting addressing examination and treatment for emergency medical conditions and women in labor. During an observation of the ED on 12/30/2024 after 2:28 p.m., a smaller waiting room was noted to have family members waiting in it. There were no required rights posting addressing examination and treatment for emergency medical conditions and women in labor in the area. Staff #4 confirmed there were no postings in the waiting areas.”