HospitalInspections.org

Based on record review and interview the facility failed to accurately track vaccine status and implement their contingency plan per policy when staff do not provide proof of vaccination or apply for an exemption in 1 of 17 staff vaccination records reviewed (Registered Nurse (RN) G).

Findings Include:

Review of policy and procedure titled, "COVID-19 Vaccination" Origination Date of 12/31/2021 revealed the following:
1. Absent an approved exemption or approved delay, all Eligible Staff are required to have received the first dose of a Two Dose Vaccine series against COVID-19, or a full dose of a Single Dose Vaccine on or before January 27, 2022.
2. Eligible Staff not in compliance with this policy must not enter the hospital and or ancillary buildings unless seeking evaluation or treatment for an emergency medical condition or unless otherwise approved by hospital, and may be subject to discipline as provided in this policy.
3. Current unvaccinated eligible staff will not be permitted to work after January 27, 2022 until the exemption request has been received and approved.

Review of the facilities vaccination spread sheet on 02/14/2022 revealed that RN G worked in the Emergency Department (ED) and was hired on 04/29/2019. Per review of the vaccination spread sheet, "None" was documented for RN G's "Covid 1" and "Covid 2" vaccinations.

Review of ED RN G's Vaccination records with Employee Health RN E and Employee Health RN F on 02/14/2022 at 11:00 am, revealed that there was no documented evidence of ED RN G receiving a COVID-19 vaccination.

Per interview with RN E on 02/14/2022 at 11:00 am, RN E stated the facility vaccination rate was 100%. Upon review of RN G's vaccination record, the facility vaccination record decreased to 99%.

Per interview with RN E and RN F on 02/14/2022 at 11:25 am, ED RN G did not have a Medical exemption or Religious exemption. RN E stated that he/she sent ED RN G an email on 11/26/2021 requesting evidence of vaccination or an exemption form and ED RN G never responded to the email. RN E stated she/he has not followed up with ED RN G since the email. RN E stated that ED RN G was still currently working night shift in the ED and had not been subject to the facility's contingency plan as per policy. Per interview, RN F stated that according to Human Resources (HR) M, ED RN G must have "slipped through the cracks."