HospitalInspections.org

Based on staff interview and review of the facility policy entitled "COVID-19 Vaccination Policy," the facility failed to ensure the established facility policy included the following required components: 1) A process for ensuring the implementation of additional precautions for staff who were not fully vaccinated; 2) A process for tracking and securely documenting the COVID-19 vaccination status for staff that obtained the COIVD-19 booster and 3) a process for contingency plans for staff who were not fully vaccinated for COVID-19. The facility's vaccination rate was 100% (87% vaccinated and 13% with approved exemptions).

The findings include:

Review of the facility's policy entitled, "COVID-19 Vaccination Policy," revealed the policy did not have procedures to address how the facility would track and document staff who had been fully vaccinated, a procedure to track and document staff who obtained COVID-19 booster vaccinations, a contingency plan for staff who were not vaccinated or a procedure for additional precautions that would be taken to mitigate the spread of COVID-19.

Review of the staff vaccination records revealed 87% of the hospital staff were fully vaccinated and 13% of the staff had approved exemptions. Vaccinated and unvaccinated direct care staff were observed to follow infection control procedures during the days of the survey. Support Technician #1 was observed wearing an N-95 respirator on 6/7/22 at 3:43 p.m. At the time of the observation, she stated she was not vaccinated. Registered Nurse #1 was observed on 6/7/22 wearing an N-95 respirator at 3:50 p.m. Upon inquiry, he said he was unvaccinated. During an interview with Unit Supervisor #1 at the time of the observations, she stated that staff vaccination status was confidential. She further stated they was no monitoring system to ensure unvaccinated staff wore the appropriate equipment to mitigate the spread of COVID-19.

During an interview with the Director of Occupational Health (DOH) on 6/7/22 at 10:15 a.m., she indicted the facility had an internal process where employees "turned in" when they received booster vaccinations, but there was no written policy or procedure. She confirmed the facility had no written policy and procedure addressing a contingency plan for unvaccinated staff. The DOH indicated it was the facility's human resource policy to hire only fully vaccinated staff and the hospital had not included this process in the written procedures. She confirmed the written policy did not include all the required components and presented revisions addressing the missing areas for review by the team.