HospitalInspections.org

Based on interview and record review, the CAH failed to develop and implement comprehensive policies and procedures that ensured all staff were fully vaccinated for COVID-19. Findings include:

Per review of the policy, "Copley Healthcare Worker Covid-19 Vaccination Policy", revised 4/7/22, the facility mitigation strategies and contingency plans were not comprehensive and/or updated for all staff who were not fully vaccinated for COVID-19.

Per interview on 5/18/22 at 1:00 PM with the Director of Quality and Chief Administration and HR Officer, they confirmed that the facility policy was not comprehensive and did not reflect current regulatory guidance.

Per review of the medical exemptions for 2 of 3 staff members, the exemptions did not reflect the CDC recognized clinical contraindications for COVID-19 vaccines.

During an interview on 5/18/22 at 1:52 PM, with the Employee Health Nurse and Chief Administration and HR Officer, they confirmed that the 2 of the 3 staff members reviewed did not have medical exemptions based on the CDC recognized clinical contraindications for COVID-19 vaccines.

Based on interview and record review the CAH failed to develop comprehensive policies and procedures for Swing Bed residents that prohibit and prevent, abuse, neglect, exploitation, and misappropriation of property. Findings include:

Per review of the policy, "Patient/Swing Bed Residents Abuse Reporting: Adult", revised 12/28/21. There was no evidence that the policy and/or procedure contained the time frame in which allegations involving abuse, neglect, exploitation, or mistreatment, to include injuries of an unknown origin and misappropriation of residents' property were reported, and to the required officials. There was also no indication of the process in which these allegations were to be fully investigated and if substantiated the appropriate corrective actions that would be taken.

Per interview on 5/18/22 at 12:00 PM with the Director of Quality, S/He confirmed that the policy did not have the required time frame for reporting and to whom; and did not have a process for fully investigating allegations if substantiated and the corrective actions that would be taken.