HospitalInspections.org

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Based on interview and document review, the hospital failed to develop and implement policies and procedures, to track vaccination status including ensuring temporary medical exemptions included dates of expiration (Item #1); for exemption requests (Item #2); for accommodation contingencies (Item #3); for infection prevention requirements including fit testing for N95 particulate respirator masks (Item #4), and education to mitigate the transmission of COVID-19 for unvaccinated staff (Item #5).

Failure to develop and implement policies and procedures for tracking mandatory vaccinations against COVID-19, exemption requests and accommodations approvals, and ensuring staff comply with infection control requirements for fit testing places patients, visitors, staff, and the community at risk for illness, disability, and death.

Findings included:

Item #1 Tracking of vaccination status and expiration dates for temporary medical exemptions

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy and Procedure," #11102201 approved 01/27/22, showed that there was no provision for tracking booster shots or expiration dates for medical exemptions for temporary conditions.

2. Record review of the hospital's employee list with vaccination status showed that employees were vaccinated or exempted (religious or medical). There was no date of vaccinations, date of boosters, or date of expiration of temporary medical exemptions.

3. On 02/02/22 at 11:30 AM, during an interview with the investigator, the Director of Quality (Staff #23) confirmed that the policy did not have any tracking requirements and the employee list with vaccination status did not contain the dates of of vaccinations, boosters or expiration of temporary medial exemptions.


Item #2 Exemption Requests

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy and Procedure," #11102201 approved 01/27/22, showed that approval for religious exemptions would be reviewed and approved by the Religious Exemption Review Committee.

2. Review of the employee files for 7 of 7 staff members granted COVID-19 vaccination exemptions for religious reasons showed that there was no evidence that the hospital committee reviewed the requests (Staff #7, Staff #12, Staff #14, Staff #19, Staff #21, Staff #25, and Staff #34).

3. Review of the employee files for 5 of 12 staff members who applied for exemption (either medical or religious) from COVID-19 vaccination showed that the exemption requests were neither approved nor denied (Staff #7, Staff #12, Staff #14, Staff #19, Staff #32).

4. On 02/02/22 at 11:00 AM, during an interview with the investigator, the Director of Quality (Staff #23) confirmed that exemption forms did not include approval or denial for 5 of 12 exemption forms reviewed.

5. On 02/02/22 at 2:12 PM, during an interview with the investigator, the Director of Quality (Staff #23) stated that the Religious Exemption Review Committee had not met.


Item #3 Accommodation

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy and Procedure," #11102201 approved 01/27/22, showed that: a) unvaccinated staff who have been granted an exemption to COVID-19 vaccination requirements will be required to utilize one of the following based on their individual circumstances: Physical distancing of a minimum 6 feet away from all other individuals (such as an unshared area), wear an N95 mask or work remotely 100% of the time.

2. On 02/15/22 at 9:52 AM, the investigator toured the radiology department. The observation showed a small office labeled as Technologist Office. The office furniture included an L shaped desk and 3 office chairs. There was less than 6 feet between the chairs, and no signage requiring a maximum capacity, social distancing, or masking requirement.

3. On 02/15/22 at 9:52 AM, during an interview with the investigator, the Director of Radiology (Staff #25) stated that there were usually 6 radiology technicians/technologists on duty at a time and the technologist office was shared.

4. On 02/15/22 at 9:52 AM, during an interview with the investigator, the Director of Radiology (Staff #25) and the Quality Improvement Coordinator (Staff #26) confirmed the investigator's observation.


Item #4 N95 Mask Fit Testing.

1. Record review of the hospital policy titled, "Respiratory Fit Testing Policy and Procedure," #9584033 approved 04/07/21, showed that all regularly scheduled clinical, environmental service, and maintenance staff are required to have annual documentation of fit testing. Staff that do not have annual documentation of fit testing are restricted from entering an Airborne Respiratory Isolation room. Annual results would be filed in each employee's Employee Health Record.

2. Review of the employee files for 10 of 10 staff members showed that there was no evidence that the staff members had been fit tested for N95 particulate respirator masks (Staff #10, Staff #25, Staff #27, Staff #28, Staff #29, Staff #30, Staff #32, Staff #33, Staff #34, and Staff #36).

3. On 02/15/22 at 9:52 AM, during an interview with the investigator, the Director of Radiology (Staff #25) stated that they had not been fit tested for the N95 mask they were wearing and that the facility did not have anyone certified to perform the fit testing.

4. On 02/15/22 at 10:10 AM, during an interview with the investigator, a staff nurse (Staff #28) stated that they had not been fit tested. The hospital had switched to Powered Air Purifying Respirators (PAPRs) several years ago due to the low rate of tuberculosis in their area. PAPRs did not require fit testing, so fit testing was discontinued at the hospital.

5. On 02/15/28 at 1:45 PM, during an interview with the investigator, the Chief Nursing Officer (Staff #31) stated that the hospital policy was not followed. They stated that the hospital recognized that they needed to purchase fit testing supplies and had ordered the supplies.


Item #5 Unvaccinated Staff Education

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy and Procedure," #11102201 approved 01/27/22, did not show that staff members who were granted exemptions were to be offered vaccination, fit tested for N95 respirators, or educated about the hospital policy for unvaccinated staff.

2. Review of the employee files for 12 of 12 staff members granted COVID-19 vaccination exemptions (either medical or religious) showed that there was no documentation of staff being offered vaccination, fit tested for N95 respirators, or educated about the hospital policy for unvaccinated staff (Staff #5, Staff #6, Staff #7, Staff #12, Staff #14, Staff #16, Staff #17, Staff #19, Staff #21, Staff #25, Staff #33, and Staff #34).

3. On 02/15/22 at 11:00 AM, during an interview with the investigator, the Director of Quality (Staff #23) confirmed that the hospital policy did not include education requirements for unvaccinated staff members.