HospitalInspections.org

Based on document review and interview, it was determined that for 1of 46 (E#4-hospital registry occupational assistant) employees, 1 of 3 (MD #4) physicians, 1 of 1 agency respiratory therapist (E #10) and 3 of 3 agency nurses (E #11, E #12 and E #13) reviewed for weekly COVID-19 testing, the Hospital failed to ensure a process for ensuring the implementation of additional precautions, intended to mitigate the transmission and spread of COVID-19, for all staff who are not fully vaccinated.

Findings include:

1. On 4/4/2022, the Hospital's policy titled, "COVID-19 Mandatory Weekly Testing" (undated) was reviewed and required, "Employees who work one or more days in a given week and who fail to undergo testing that week as required... may not return to the workplace the following week until they participate in testing..."

2. On 4/4/2022, an internal e-mail dated 9/18/2021, sent by the Interim President (E #9) was reviewed and included, "Per Illinois Governor J.B. Pritzker, under the state order, employees who have received approved medical or religious exemptions from vaccinations must undergo weekly testing ... Beginning Monday, September 20, 2021."

3. On 4/4/2022 the individual weekly testing results of non-vaccinated employees with exemptions were reviewed. The following active employees and active agency staff members were missing weekly COVID-19 testing as follows:
-MD #4 (physician) - no testing the week of 3/21/2022. MD #4 worked the week of 3/21/2022.
-E#4 (hospital registry occupational assistant) - no testing the week of 2/28/2022. E #4 worked on 3/5/2022. There was no testing the week of 3/7/2022. E #4 worked on 3/12/2022.
-E #10 (agency respiratory therapist) - no testing documented from 2/14/2022 thru 3/28/2022. E #10 worked on 3/7/2022, 3/9/2022, 3/10/2022, 3/14/2022, 3/19/2022, 3/20/2022, 3/22/2022 and 3/28/2022.
-E #11 (agency registered nurse) - no testing documented from 2/14/2022 thru 3/28/2022. E #11 worked on 2/14/2022, 2/17/2022, 2/18/2022, 2/19/2022, 2/22/2022, 2/24/2022, 2/25/2022, 2/26/2022, 2/27/2022, 2/28/2022, 3/1/2022, 3/3/2022 and 3/4/2022.
-E #12 (agency registered nurse) - no testing documented from 2/14/2022 thru 3/28/2022. E #12 worked on 3/4/2022, 3/5/2022, 3/6/2022, 3/7/2022, 3/12/2022, 3/13/2022, 3/14/2022, 3/18/2022, 3/21/2022, 3/25/2022 and 3/26/2022.
-E #13 (agency registered nurse) - no testing documented from 2/14/2022 thru 3/28/2022. E #13 worked on 2/25/2022, 3/3/2022, 3/4/2022, 3/9/2022 and 3/25/2022.

4. On 4/4/2022 at 1:00 PM, an interview was conducted with the Director of Occupational Medicine (E#8). E #8 stated that she is responsible for ensuring the weekly testing is complete.

5. On 4/5/2022 at 11:15 AM, an interview was conducted with the Director of Clinical Excellence (E #2). E #2 stated that weekly testing should be done for all unvaccinated staff.