HospitalInspections.org

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Based on document review and interview, the hospital failed to ensure that unvaccinated staff with an approved exemption completed required COVID-19 education for 1 of 8 unvaccinated exempt staff reviewed.

Failure to have exempt staff complete required education on COVID-19 precautions and vaccination risks unsafe practices that could lead to patient and staff infection.

Findings included:

1. Record review of the hospital policy titled, "SRH COVID Vaccine Healthcare Worker Requirement," policy number 159992, effective 03/17/22, showed that staff with an approved vaccine exemption are required to complete designated trainings yearly as a part of the accommodation process.

2. Record review of clinical education files showed that 1 staff (Staff #1701) that had approved exemptions from COVID-19 vaccination had not completed the required COVID-19 learning course.

3. On 04/12/22 at 1:20 PM, Investigator #17 interviewed the Regional Director of Accreditation (Staff #1709) about the required education. Staff #1709 stated that the education was required for unvaccinated exempt staff and confirmed that Staff #1701 had not completed the required education at the time of review.