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Based on clinical record review, staff interview, and facility policy/procedure review, it was determined the facility staff failed to ensure authorization/general consent for treatment was obtained from the patient for three (3) of five (5) applicable records reviewed in the survey sample. Clinical record #'s 3, 4, and 5.

The findings include:

Five (5) clinical records containing authorizations for treatment were reviewed 02/28/22 - 03/01/22. Three (3) of five (5) of these documents were not filled out completely and/or did not contain the patient's signature.

1. The clinical record for patient #3 contained a general consent/authorization for hospital treatment form dated by the hospital representative for 6/7/21. The form contained the words "verbal consent" and a section stating patient unable to sign: reason "verbal." The clinical record failed to contain documentation of who the consent was obtained from or why verbal consent was obtained. The clinical record failed to contain documentation of any evidence that the patient and/or representative was unable to sign due to emergency, altered mental status, or refusal.

2. The clinical record for patient #4 contained a general consent/authorization for hospital treatment form dated by the hospital representative for 6/2/21. The form was not signed by the patient and/or representative and contained no documentation that indicated the form had been reviewed or acknowledged by the patient. The clinical record failed to contain documentation of any evidence that the patient and/or representative was unable to sign due to emergency, altered mental status, or refusal.

3. The clinical record for patient #5 contained a general consent/authorization for hospital treatment form dated by the hospital representative for 6/14/21. The form contained the words "verbal consent" and a section stating patient unable to sign: reason "verbal." The clinical record failed to contain documentation of who the consent was obtained from or why verbal consent was obtained. The clinical record failed to contain documentation of any evidence that the patient and/or representative was unable to sign due to emergency, altered mental status, or refusal.

The clinical records were reviewed and discussed with the Director of Quality and Patient Safety (staff member #1) on 03/01/22 at 11:00 AM who confirmed the authorization for treatment/general consent forms were not completed filled out, lacked patient signatures, and/or reasons that verbal consents were obtained. The medical records were reviewed with staff member #1 who confirmed the records did not contain documentation that patients would have been unable to sign due to medical or emergency reasons.

An interview was conducted with the Emergency Department Registration Manager (staff member #9) at 2:30 PM on 02/28/22. Staff member #9 stated that verbal consents had been obtained periodically the last two years because of the pandemic. Staff member #9 confirmed registration staff should document verbal consent, the staff members name obtaining consent, and the reason for verbal consent on the authorization for treatment/consent for general treatment form.

The Medical Facilities Inspector requested the facility's policy for obtaining consents and any additional policies/procedures/protocols for obtaining verbal consent during the pandemic. The AVP of Quality (staff member #2) confirmed the facility did not have a policy related to changes in obtaining verbal consent during the pandemic. The facility's policy, "Consent Policy" was reviewed and did not address obtaining verbal signatures for general consent for treatment.

Based on staff interview and document review, it was determined the facility failed to implement its policies and procedures to ensure all staff were fully vaccinated for COVID-19. Additionally, the facility failed to ensure COVID vaccination status was known for all staff. Approximately 99 percent of facility staff were fully vaccinated, partially vaccinated, exempt, or temporarily delayed from receiving the COVID-19 vaccine. One (1) percent of staff vaccine status was unknown, undocumented, or not vaccinated.

Findings:

The facility staff provided documentation that 3337 staff members were fully vaccinated against COVID-19, 52 were partially vaccinated, 101 were exempt, and 0 staff members were temporarily delayed from receiving the vaccine. The facility identified 3542 staff members subject to the vaccine requirements. Three thousand four hundred ninety (3490) out of 3524 applicable staff members (approximately 99 percent) were fully or partially vaccinated, exempt, or temporarily delayed. Approximately one (1) percent of staff members were not vaccinated (and had no exemption) or vaccine status unknown or not documented.

The facility's policy, VHC Vaccination Policy was reviewed and partially reads as follows: All current and any new VHC staff, contractors, medical staff member performing services at any VHC facility or offiste, and VHC board members, with limited exceptions, must be vaccinated against COVID-19 as required by applicable law prior to providing any care, treatment, or other services for VHC and/or its patients at any VHC facility. All individuals subject to this policy must provide proof of vaccination or exemption.

An interview was conducted with the facility's Employee Health (staff member #15) responsible for tracking COVID vaccines for employees on 02/28/22. Staff member #15 confirmed some staff had not yet been vaccinated or received an exemption. The staff member stated the facility has given employees until the end of March to be vaccinated or exempt. Staff member #15 stated that all nonvaccinated personnel were required to wear n-95 respirators at all times.

The AVP of Quality confirmed the lack of 100 percent compliance with the staff COVID-19 vaccination requirement on 03/01/22 at 11:15 AM.