HospitalInspections.org

Based on interview and record review, it was determined that the facility failed to develop and implement policies and procedures that included a process for accurately tracking and documenting the COVID-19 vaccination status of all staff, and failed to accurately document the COVID-19 vaccination status for 2 out of 9 staff reviewed for COVID-19 vaccination status. (Staff identifiers are D and E.)
Finding include:

Review on 6/8/22 of the hospital's COVID-19 Staff Vaccinations Status for Staff Roster that was provided in the morning of 6/8/22 revealed the vaccination status were as follows:
- 1599 total staff; 5 partially vaccinated; 63 granted exemption (medical and non-medical), 9 temporary delay/new hire, and 1 unvaccinated staff without exemption/ temporary delay. Further review of the roster, line by line, revealed 33 staff granted medical exemption, 1 non-medical exemption and 37 "exempt" (for total of 71), and 4 partially vaccinated.

Review on 6/8/22 of Staff D's (Registered Nurse) vaccination records revealed that Staff D worked as direct care staff and had been granted a medical exemption for the COVID-19 vaccination. Further review of Staff D's exemption request form revealed that Staff D had a religious exemption request and not a medical exemption as listed on the above mentioned roster.

Review on 6/8/22 of Staff E's (Licensed Practical Nurse) vaccination records revealed that Staff E worked as direct care staff and was listed as 'unvaccinated' and "not vaccinated without exemption/delay". Further review of Staff E's vaccination records revealed that Staff E had a religious exemption dated 9/9/21.

Interview on 6/8/22 at 12:25 p.m. with Staff A (Vice President of Human Resources) and Staff B (Employee Health staff) revealed that they did not have access to the third party vaccination tracking system that the facility used.

Interview on 6/8/22 at 12:45 p.m. with Staff B revealed that the Employee Health System could track if the employee was vaccinated or exempt only. Both Staff A and B did not think that there were any staff with medical exemptions for COVID-19 vaccination. Staff A did not know if anyone in the facility validated what the external company tracked was correct.

Review on 6/8/22 of an updated COVID-19 Staff Vaccinations Status for Staff Roster, provided by Staff A and Staff B, revealed the total number of employees was 1598, 3 partially vaccinated (two of the 3 had a note saying Fully Vaccinated), 1 medical exemption, 71 non-medical exemption, 0 temporary delay/new hire, and 0 not vaccinated without delay.

Review on 6/8/22 of the hospital's policy and procedure titled "Immunization Requirements and Exemption Policy - Employees, Covered Individuals" approval date of 8/6/21 revealed that the policy did not include components for tracking the vaccination and securely documenting the COVID-19 vaccination status for staff, including staff for whom COVID-19 vaccination requirements must be temporarily delayed as recommended by the CDC.

Interview on 6/8/22 at 1:10 p.m. with Staff C (Associate Chief Nursing Officer) revealed that the above policy and procedure did not include a component for tracking and would double check that there was not an updated policy.

Interview on 6/8/22 at 1:55 p.m. with Staff A revealed that the tracking the COVID-19 vaccination status was an internal procedure and not part of the hospital's policy.