HospitalInspections.org

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Based on interview and document review, the hospital failed to ensure 100% compliance with the infection control COVID-19 vaccination requirement. Specifically, the hospital failed to ensure all staff had either been fully vaccinated, or had an exemption or accommodation, as authorized by law, granted. Failure to meet the requirement may place staff and patients at greater risk for SARS-CoV-2 exposure and infection. Findings:

Review on 3/4/22 at 8:30 AM of the hospital staff initial vaccination status, revealed a high percentage of the vendors and providers had unknown vaccination status.

An interview on 3/4/22 at 8:30 AM with the Program Manager Regulatory Compliance (PMRC), stated they were still working on the vaccination status of the vendors and providers. PMRC explained that vendors were not providing direct patient care but working on construction projects in the patients' room or in the building. PMRC also explained that the providers on the list were non-employee hospitalists that provided direct patient care.

An interview on 3/4/22 at 10:00 AM with Human Resources Manager (HRM) stated that they had a plan in place and had been working with companies and stakeholders to provide their vaccination status. HRM also stated their initial target of compliance would be on 3/15/22 and final target would be on 5/15/22.

During this interview, when asked what the hospital had done to meet the staff vaccination requirement for the first 30 days of the approval of the Quality Standard Oversight (QSO) Memorandum (Memo) [22-09-ALL], HRM stated, since January they were analyzing potential outliers, reaching out to employees and workforce groups, and fine tuning the deadlines.

An interview on 3/4/22 at 2:21 PM with Provider #1 who had "unknown" vaccination status, stated he/she was vaccinated with two doses and a booster shot. Provider #1 also confirmed that the vaccination was a requirement of the hospital.

An interview on 3/4/22 at 3:39 PM with Licensed Nurse #1, stated he/she was unvaccinated and had a religious exemption. The hospital provided LN #1 with accommodation such as testing before going to work. If symptomatic [of COVID-19], LN#1 was to call in sick and get tested. The hospital also educated the LN how and where to get the vaccine if LN decided to get one. The LN further stated the use of N95, face shield or googles were required when providing patient care.

Review on 3/4/22 at 4:33 PM of the updated hospital's staff vaccination status revealed a total of 4,270 health care providers (HCP) with a compliance rate of 90.1% wherein, 86% of the staff were fully vaccinated, 0.1% had partial vaccination and 4% were exempted [from receiving vaccination for medical or religious reasons]. The remaining 10% had unknown status.

An interview on 3/4/22 at 4:35 PM with the Program Manager Regulatory Compliance, stated there was no more additional information in the providers unknown vaccination status at that time because they were still processing their "bylaws." Further stating their target date to comply on the vaccination requirement would be on March 15, 2022.

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