HospitalInspections.org

Based on document review and interview, it was determined the hospital failed to ensure that documentation for each staff member who was medically exempt from COVID-19 vaccination contained evidence of the recognized clinical contraindications to COVID-19 vaccines in one (1) of two (2) medically exempt personnel reviewed in the survey sample. Personnel file #11. Additionally, the hospital failed to ensure all staff were fully vaccinated against COVID-19. The hospital identified 19 employees who were past due for the second dose of vaccination in a multi-dose vaccine series; 1 staff member not vaccinated with a rejected request for exemption; 58 staff members with no documentation of receiving a vaccine out of a total of 3291 staff members.

Findings:

Two (2) records of staff members with medical exemptions to the COVID-19 vaccine were reviewed on 04/18/22. The documentation for personnel file #11 contained a request for medical exemption that was signed by a licensed practitioner. The document contained a checkmark next to the following statement: "My patient has a physical or mental impairment that substantially limits one or more major activities and prevents the patient from safely receiving the vaccine. (More detail regarding the medical condition and how it prevents the patient from receiving the vaccine must be attached)". The practitioner signed the form 11/10/21 and handwrote "may consider vaccine 11/10/22," but provided no additional information related to a recognized clinical contraindication to receiving the vaccine. No documentation was attached to the exemption request form.

An interview was conducted with the Vice President of Human Resources (staff member #4) on 04/18/22 who confirmed the lack of a documented recognized contraindication to the vaccine for personnel file #11. Staff member #4 also presented the surveyor with the numbers of vaccinated and exempt staff members to include identifying staff members who had not yet received the vaccine, an exemption, or the second dose of a vaccine in a two vaccine series. Staff member #4 identified 19 employees who were past due for the second dose of vaccination in a multi-dose vaccine series; 1 staff member not vaccinated with a rejected request for exemption; and 58 staff members with no documentation of receiving a vaccine out of a total of 3291 staff members.

The hospital's policy, COVID-19 Vaccination Requirements for Employees and Staff of HCA CMS Mandate Facilities was reviewed and partially reads as follows: Exemption Requests: Staff may request an exemption from the COVID-19 vaccination requirements in this policy based on an applicable federal law...(b) staff who desire accommodation based on a disability or medical condition shall submit an exemption request by having the Medical Exemption Request form completed by a licensed healthcare provider and submitting the form and any supporting documents to https://hcacovidvaccine.com/ or by other electronic means provided by the company. The documentation for a medical exemption request at a minimum shall contain (A) information specifying which of the authorized COVID-19 vaccines are clinically contraindicated for the staff member to receive and the recognized clinical reasons for the contraindications and (B) A statement by the authenticating practitioner recommending that the staff member be exempted from the COVID-19 vaccination requirements for staff based on the recognized clinical contraindications.

The above noted findings were discussed and confirmed by hospital administration staff during the exit conference on 04/19/22.