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 5 out of 5 Staff (I, J, K, L and M), that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 122 patients being served by the facility. Findings include:

On 2/1/2022 at 1030 during an interview with Chief Nurse Officer (Staff A) when queried regarding their policy/procedure for Health Care Staff Vaccination for COVID-19 immunization she replied at that time, "It's mandatory for all staff unless they have medical or religious exemptions."

On 2/2/2022 at 1130 a review of employee exemptions records for Staff I, J, K, L and M revealed the following:

Staff I was a Registered Nurse. She was granted her request for Religious Exemption on 1/4/2022.

Staff J was a phlebotomist. She was granted her request for Religious Exemption on 9/5/2021.

Staff K was a Ophthalmology Resident Physician who was granted her request for Religious Exemption on 9/5/2021.

Staff L was a Certified Surgical Assistant. She was granted her request for Medical Exemption on 9/8/2021. It was noted that it would be okay for her to receive the vaccine post pregnancy.

Staff M was a Surgical Assistant. She was granted her request for Medical Exemption on 8/31/2021 for a time limited deferment during pregnancy.

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..."

Staff A was queried on 2/2/2022 at 1315 was regarding the type of mask and frequency of COVID-19 testing for staff who were granted exemptions from vaccination. At that time, she (Staff A) replied, "a regular mask, a clean one not a personal mask." When asked how often staff were tested for COVID-19 she replied, all staff are screened, we (each employee) use an app for screening. When asked if staff are required to use a NIOSH (N-95) mask or undergo weekly COVID-19 testing she (Staff A) replied, "No we don't do that." We would only use an N-95 or higher for patient's diagnosed with COVID-19.