HospitalInspections.org

Based on interview and record review, the facility failed to develop and implement policy/procedure for additional precautions for all non-immunized COVID-19 health care exempt staff that included 4 out of 4 Staff (Y, Z, AA, and BB) that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 485 patients being served by the facility. Findings include:

On 2/16/2022 at 1130 a review of COVID-19 vaccination exemptions records for Staff Y, Z AA and BB revealed the following:

Staff Y was a Registered Nurse who was granted her request for Medical Exemption.

Staff Z was a Respiratory Therapist who was granted her request for Medical Exemption.

Staff AA was a Physical Therapist who was granted her request for Religious Exemption.

Staff BB was a Radiology tech. She was granted her request for Religious Exemption.

Review of the facility's "Mandatory COVID-19 Vaccine" policy dated last revised on 2/1/2022 documented the following:

II. Policy Statement:
"COVID-19 immunization is required for all Team Members...In addition to the vaccination requirements, all Team Members are expected to comply with all other safety requirements for COVID-19 based on guidance from the CDC and other applicable regulatory agencies that govern public health and safety..."

VI. Requests for Exemption:
"...D. Team Members who have an exemption granted as a valid medical or religious accommodation will be required to wear a mask in all (name of facility's) at all times and may be subject to periodic COVID-19 testing and other health and safety standards..."

The Chief Nursing Officer (Staff B) was queried on 2/16/2022 at 1245 regarding the facility's policy for unvaccinated staff with medical or religious exemptions and asked to explain if any additional precautions were taken for those staff. At that time, she (Staff B) replied, COVID testing has not changed. All staff are screened using the app. If the employee screening is "red" we have a compliance line and they are called for testing.

When asked if unvaccinated staff are required to use a NIOSH (N-95) mask or undergo weekly COVID-19 testing she (Staff B) replied, we have N-95 masks available for all staff as needed the masks are required for staff providing care to COVID positive patients. She said COVID testing is not required unless they fail the screen. She explained we are currently reviewing our policy.