HospitalInspections.org

Based on record review and interview, the facility failed to obtain weekly staff COVID-19 testing for 2 of 10 non-vaccinated employees (staff FF and staff GG) per facility policies in a sample of 16 personnel records reviewed; resulting in failure to mitigate the transmission and spread of COVID-19 for staff who are not fully vaccinated for COVID-19.

Findings include:

The facility policy, titled "Influenza and COVID-19 Vaccination Program", last updated 07/06/2021, revealed: "...Mitigation...B. COVID-19: 1. Staff with approved Exemptions or Temporary Delay of the COVID-19 Vaccine will wear a mask at all times while in any [Facility Name] facility, or while performing services on behalf of [Facility Name] in the presence of others and will follow other [Facility Name] requirements which may include weekly testing..."

The facility document, titled "Weekly Mandatory Employee COVID-19", dated 11/03/2021, revealed: "...Starting on Nov 1st, Weekly Testing reporting will shift to only reporting in Workday once a week on Tuesdays for those non-compliant staff members from the week prior. Leaders are expected to ensure that staff are performing weekly testing requirements..."

A review of staff FF's personnel record revealed that staff FF is a current/active OB/GYN (Obstetrics/Gynecology) Physician at the facility. Staff FF is unvaccinated for COVID-19 and has an active Medical Exemption on file that was signed by a Medical Provider on 09/07/2021. There was no documentation of staff FF performing weekly mandatory employee COVID-19 testing for non-vaccinated staff-per facility policies.

A review of staff GG's personnel record revealed that staff GG is a current/active ED (Emergency Department) Registered Nurse at the facility. Staff GG is unvaccinated for COVID-19 and has an active Medical Exemption on file that was signed by a Medical Provider on 07/07/2021. There was no documentation of staff GG performing weekly mandatory employee COVID-19 testing for non-vaccinated staff-per facility policies.

During an interview on 02/15/2022 at 10:00 AM with Infection Preventionist M, when asked about current facility plans to mitigate the spread of COVID-19 for unvaccinated staff, M stated "We do weekly testing for all employees who are not vaccinated, they are tested at one of our facility labs or at our main collection site."

During personnel record review and interview on 02/16/2022 at 12:16 PM, Credentialing (CVO) Manager DD confirmed that staff FF has not been vaccinated for COVID-19 and should be having weekly COVID-19 testing done.

During personnel record review and interview on 02/16/2022 at 12:18 PM, Director of Employee Health O confirmed that staff GG has not been vaccinated for COVID-19 and should be having weekly COVID-19 testing done.

During an interview on 02/16/2022 at 12:20 PM, Administrative Director E stated, "ED Director C [Name] thought staff GG [Name] was vaccinated when he/she came back from maternity leave to work on 11/29/2021, he/she 'fell through the cracks.' There is a list ran weekly for staff non-compliance and distributed to Directors, they are the ones to make sure their department staff are compliant."

During an interview on 02/16/2022 at 12:22 PM, Regional Manager of Employee Health P stated, "Weekly COVID testing started on 09/20/2021 for all unvaccinated staff."

During an interview on 02/16/2022 at 12:30 PM, ED Director C stated, "I am just learning this today about looking at the staff non-compliance, I was not aware I needed to check for vaccination compliance."