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 (M, N, O, and P) that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 193 patients being served by the facility. Findings include:

On 3/9/2022 at 1130 a review of COVID-19 vaccination exemptions records for Staff M, N, O and P revealed the following:

Staff M was a Registered Nurse who was granted her request for Religious exemption.

Staff N was a Surgical Technician who was granted her request for Medical Exemption.

Staff O was a Patient transporter who was granted her request for Religious Exemption.

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

On 3/9/2022 at 1600, Staff A was asked if unvaccinated staff were required to use a NIOSH (N-95) mask or undergo weekly COVID-19 testing. She replied, we have N-95 masks available for all staff as needed and the masks are required for staff providing care to COVID positive patients. She said COVID testing was not required.


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..."

Based on interview and document review, it was determined that the facility failed to comply with the requirements of 42 CFR 489.24 [special responsibilities of Medicare hospitals in emergency cases], specifically the failure to obtain and document consent from the [patient /guardian/responsible party] for an appropriate transfer to another facility for 3 of 3 patients reviewed for transfers (Patient's # 11, #,12, and #20) resulting in the potential for less than optimal outcomes for all patients seeking emergent care. Findings include:

1. The failure to obtain signatures for consent of transfer for patients from one hospital to another hospital for care. (See tag 2409)

Based on interview and document review, the facility failed to get authorized permission (signature) from the patient/guardian/responsible party to authorize consent for the transfer of 3 of 3 patients (Patients #11, #12, and # 20) reviewed for transfer to affirm acceptance/transfer of the patients at another facility for further treatment, resulting in an inappropriate EMTALA (Emergency Medical Treatment and Active Labor Act) transfer and the potential for unsatisfactory outcomes. Findings include:

On 03/8/2022 between the hours of 1300 and 1530, review of medical records for patients #'s 11, 12, and #20 was conducted with (Staff B, E and F) and the following was revealed:
Patient #11 was a 14-year-old minor child who was transferred from facility (A) to another hospital on 10/1/2021. Review of a form titled, "Transfer of Patient to another facility" dated 10/1/2021 was signed by the physician on 10/1/2021. However, there was no signed consent for the transfer to another facility by the patient/responsible party in the medical record.

Patient #12 was a 42-year-old female who was transferred from facility (A) to another hospital on 10/5/2021.
Review of a form titled "Transfer of Patient to another facility dated 10/5/2021 was signed by the physician on 10/5/2021. However, there was no signed consent for the transfer to another facility by the physician or the patient/responsible party in the medical record.

Patient #20 was a 56-year-old female who was transferred from facility (A) to another hospital on 3/7/2022.
Review of a form titled "Transfer of Patient to another facility dated 03/06/2022 was signed by the physician on 03/06/2022. However, there was no signed consent for the transfer to another facility by the patient/responsible party in the medical record.

On 3/8/2021 at 1535, Staff B was asked to explain why there were no documented signed consents for the transfer of the aforementioned patient's available for review in the medical records. At that time, Staff B replied the forms should have been printed and signed by the patient/responsible party. He said we will look for them to see if they were printed and not filed.

On 03/09/21 at 1545, during an interview with Staff B, he was asked if the completed forms for consent to transfer to other facility's for the patients had been found. Staff B replied, they had not.

Review of the facility's "Emergency Treatment and Active labor Act (EMTALA) policy dated, last revised on 4/18/218 documented:
IV. Definitions
A. Appropriate transfer: occurs when: "(i) the transferring hospital provides medical treatment within its capacity that minimizes the risks to the individual's health and in the case of a woman in labor, the health of the unborn child;...the transferring hospital sends to the receiving hospital all medical records....and the informed written consent for transfer or certification if applicable, and that any other records that are not readily available at the time of transfer are sent as soon as practicable after the transfer..."
However, that was not done.