HospitalInspections.org

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Based on observation, interview and document review, the hopsital failed to develop and implement policies and procedures to ensure that staff comply with precautions to prevent transmission of COVID-19 (Staff #6, Staff #8, Staff #11, and Staff #12) (Item #1), and for fit testing of N95 particulate respirator masks for 15 of 15 staff (Staff #6, Staff #7, Staff #10, Staff #11, Staff #15, Staff #17, Staff #18, Staff #19, Staff #20, Staff #21, Staff #22, Staff #23, Staff #24, Staff #25, and Staff #26) (Item #2).

Failure to ensure compliance with precautions to prevent COVID-19 transmision, and to develop and implement policies and procedures for fit testing places patients, staff, visitors and the community at risk for illness, disability and death.

Findings included:

Item #1 Precautions to prevent transmission of COVID-19

1. Review of the hospital policy titled, "Universal Masking and Eye Protection," #11150335 approved 02/22, showed that the hospital was adopting a policy on universal masking for patients, visitors, and staff per the Centers for Disease Control's (CDC) recommendations. Universal masking within healthcare settings was a critical tool to protect staff and patients from being infected by asymptomatic and pre-symptomatic individuals. All employees were expected to wear a hospital issued mask in all clinical departments and always applied while in the building unless they are in their personal workspace.

2. During a tour of the hospital, on 02/25/22 at 10:25 AM, the investigator observed a laboratory technician (Staff #6) not wearing a mask in a department with 3 people in it.

3. On 02/25/22 at 10:25 AM, the Director of Quality (Staff #3) confirmed that Staff #6 was not following hospital policy for universal masking and counseled Staff #6 to put on a mask.

4. During a tour of the hospital's Emergency Department (ED) on 02/25/22 at 10:30 AM, the investigator observed that the ED physician (Staff #12) was sitting in the nurse's station without a mask on.

5. On 02/25/22 at 10:30 AM, the Director of Quality (Staff #3) confirmed that the physician was not following hospital policy.

6. On 02/25/22 at 10:40 AM, the investigator entered the Radiology Department office and observed 3 employees talking together (Staff #8, Staff #9, and Staff #10). Staff #8 stated that they were taking a drink from their cup, so they were allowed to have their mask off.

7. On 02/25/22 at 10:40 AM, the Director of Quality (Staff #3) stated that the office was not a break room, and having a beverage was to be done in the cafeteria. Staff #3 confirmed that hospital policy was not followed.

8. On 02/25/22 at 11:00 AM, the investigator entered the Pharmacy Department and observed an employee (Staff #11) eating at the desk near another staff member.

9. On 02/25/22 at 11:00 AM, the Director of Quality (Staff #3) counseled staff #11 to only eat in the cafeteria or a breakroom. Staff #3 confirmed that hospital policy was not followed.


Item #2 N95 Fit Testing

1. Review of the hospital policy titled, "Respiratory Protection Plan" #9504105 approved 04/21, showed that the program applied to all employees who are required to wear respirators during normal work operations and during certain non-routine or emergency operations. Employees would be trained prior to using a respirator in the workplace. Each employee was responsible to wear their respirator when and where required and in the way they were trained. The procedure required a medical evaluation with written recommendations, a medical questionnaire, and fit testing. The facility would retain a copy of the provider's written recommendation for each employee, competed medical questionnaire, and fit test records.

2. Review of employee files showed that there was no evidence of medical evaluations, or medical questionnaires for 10 of 10 employees who were fit tested for N95 respirator masks (Staff #6, Staff #7, Staff #18, Staff #20, Staff #21, Staff #22, Staff #23, Staff #24, Staff #25, and Staff #26).

3. Review of the employee files for 15 staff members showed that 6 of 15 had not been fit tested for N95 masks (Staff #7, Staff #10, Staff #11, Staff #15, Staff #17, and Staff #19). Of the 6 staff members that had not been fit tested for N95 masks, 5 were unvaccinated (Staff #7, Staff #10, Staff #15, Staff #17, and Staff #19).

4. On 02/25/22 at 3:20 PM, during an interview with the investigator, the Director of Human Resources (Staff #5) confirmed that the hospital policy for fit testing was not followed.

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Based on interview, and document review, the hospital failed to develop and implement policies and procedures to approve requests and accommodations for medical exemptions from COVID-19 vaccination for 5 of 5 staff (Staff #27, Staff #28, Staff #29, Staff #30, and Staff #31) (Item #1), for religious exemptions for 2 of 9 staff (Staff #17 and Staff #23) (Item #2), and to ensure that staff comply with additional precautions to prevent the transmission of COVID-19 (Item #3).

Failure to develop policies and procedures to approve requests for medical and religious exemptions for COVID-19 vaccinations, to determine accommodations for unvaccinated staff, and ensure compliance with additional precautions to prevent transmission of COVID-19 places patients, staff, visitors and the community at risk of illness, disability and death.

Findings included:

Item #1 Medical Exemption Requests

1. Review of the hospital policy titled, "Implementing Proclamation 21-14 COVID-19 Vaccination Requirement/CMS Vaccine Mandate_QSC-2207" no number or date, showed that employees, medical staff, and volunteers were to provide proof of vaccination no later than 10/18/21. Exemptions from vaccination requirements would be allowed for disability related reasonable accommodations and reasonable accommodations for a sincerely held religious belief. Reasonable accommodations would be determined on an individualized basis depending on facts and circumstances and might include remote work, additional PPE requirements and mandatory testing, or reassignment.

2. Review of the 5 requested medical exemptions showed that all were signed by a medical provider, but 5 of 5 were missing the specific vaccine contraindication and clinical reason for the exemption (Staff #27, Staff #28, Staff #29, Staff #30, and Staff #31).

3. On 02/25/22 at 3:20 PM, during an interview with the investigator, the Director of Human Resources (Staff #5) stated that the medical exemption forms were old forms used prior to the CMS vaccine mandate. They stated that they had already sent the updated forms to each of the 5 people with medical exemptions to have them completed by their provider and resubmitted to Human Resources. At the time of the interview, none of the updated forms had been returned to Human Resources.


Item #2 Religious Exemption Requests

1.Review of the hospital policy titled, "Implementing Proclamation 21-14 COVID-19 Vaccination Requirement/CMS Vaccine Mandate_QSC-2207" no number or date, showed that employees, medical staff, and volunteers were to provide proof of vaccination no later than 10/18/21. Exemptions from vaccination requirements would be allowed for disability related reasonable accommodations and reasonable accommodations for a sincerely held religious belief. Reasonable accommodations would be determined on an individualized basis depending on facts and circumstances and might include remote work, additional PPE requirements and mandatory testing, or reassignment.

2. Review of the 9 religious exemptions showed that 2 of 9 did not include approval or denial by the hospital and there were no accommodations or contingencies listed (Staff #17, and Staff #23).

3. On 02/25/22 at 2:50 PM, during an interview with the investigator, the Director of Human Resources (Staff #5) stated that they review and approve vaccine exemption requests. They confirmed that 2 religious exemption requests did not include approval or denial by Human Resources and that there were no accommodations or contingencies listed on the religious accommodation request forms (Staff #17 and Staff #23).


Item #3 Contingency plans for unvaccinated staff

1. Review of the hospital policy titled, "Implementing Proclamation 21-14 COVID-19 Vaccination Requirement/CMS Vaccine Mandate_QSC-2207" no number or date, showed exemptions from vaccination requirements would be allowed for disability related reasonable accommodations and reasonable accommodations for a sincerely held religious belief. Reasonable accommodations would be determined on an individualized basis depending on facts and circumstances and might include remote work, additional PPE requirements and mandatory testing, or reassignment.

2. On 02/25/22 at 10:22 AM, the investigator observed the employee sign-in site with hands off thermometer. On a table nearby was an employee attestation log and flyers titled, "Vaccine Mandate Update" that showed that the hospital was no longer requiring use of N95/KN95 masks or weekly testing for non-vaccinated staff effective immediately. Universal masking requirements would still be required with use of simple masks.

3. Review of the 5 requested medical exemptions showed that 5 of 5 were missing specific accommodation or contingency for unvaccinated, medically exempt staff (Staff #27, Staff #28, Staff #29, Staff #30, and Staff #31).

4. On 02/25/22 at 11:15 AM, during an interview with the investigator, the Director of Quality (Staff #3) stated that COVID-19 testing supplies were in short supply, so the facility eliminated monthly testing of unvaccinated staff and moved from N95 masks to surgical masks. The hospital had tested unvaccinated staff plus 5 random vaccinated staff each month from October 2021 through January 2022. There had been no positive COVID-19 results from that testing. Staff #3 confirmed that the QSO memo from CMS required additional precautions for unvaccinated staff and the Governor's Proclamation 21-14.3 required additional precautions for unvaccinated staff.

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