HospitalInspections.org

Based on interview and record review, the facility failed to develop and implement policy and procedure for additional precautions and contingency plans for all non-immunized COVID-19 health care exempt staff that included 3 (M, N, S) of 12 sampled staff that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all patients being served by the facility. Findings include:

On 3/2/22 at approximately 1100-1230, interview and document review with Human Resources (HR) Representative J and Medical Staff (MS) Coordinator G revealed that staff M, N, S had documented medical or religious exemptions. Facility data revealed that there were 130 exempted hospital staff out of a total of 963 staff which included nurses, physicians, volunteers, and others. HR Representative J and MS Coordinator G were both queried during the above time frame regarding any additional precautions or contingency plans for these unvaccinated exempted staff and stated they weren't aware of any. Review of the facility policy titled "XYZ Health System Mandatory COVID-19 Vaccination Policy, #CP 3.61, updated 1/18/22," revealed no documentation regarding additional precautions and/or contingency plans for unvaccinated exempted staff.

On 3/2/22 at approximately 1300, the Quality Manager A and Infection Prevention Coordinator K were queried about any additional provisions for unvaccinated exempted staff and they verified that there weren't any. They stated that unvaccinated exempted staff utilize the same precautions that all staff use, which included masking and personal protective equipment.