HospitalInspections.org

Based on observations, interview and policy review, the facility failed to ensure Emergency Department staff followed the current facility policy related to COVID-19 personal protective equipment (PPE). This had the potential to affect all patients receiving care in the Emergency Department. The census in the Emergency Department was 18.

Findings include:

The facility's Emergency Department was toured on 05/03/22 at 10:50 AM. There were no staff that were observed wearing eye protection. Three staff members were observed providing care to patients in room #1, room #5, and room #24. None of the staff members were wearing eye protection.

The facility policy titled "COVID-19 PPE Guide WHAT to wear and WHEN to wear it", effective 12/23/21, documented Emergency Department staff members are instructed to wear eye protection during all patient encounters.

These facts were confirmed during an interview with Staff B on 05/11/22 at 11:45 AM.

Based on review of QSO memo 22-09-ALL, Attachment D, record review, interview and policy review, the facility failed to to implement a process for tracking the COVID-19 vaccination status of all staff and failed to ensure a contingency plan and/or procedures were in place for unvaccinated staff to mitigate the transmission and spread of COVID-19. This had the potential to affect patients, staff, and visitors in the hospital. The active census was 238.

Findings include:

1. Review of the facility document titled "Active Worker COVID Vaccine Compliance by Status for Surveyors" listed eight staff members that had been granted a medical exemption from the COVID-19 vaccine, 107 staff members that had been granted a religious exemption and 992 staff members that were fully vaccinated. There were two new hires, one staff member on leave, and one staff member with a temporary delay. There were 1111 employees with a vaccination rate of 100 percent.

Review of a list of all staff, excluding contracted staff, with their vaccination status, and job title revealed no physicians were on the list.

During interview on 05/03/22 at 12:45 PM. Staff H stated there are physicians that are not contracted. Staff H stated the hospital does not have a comprehensive tracking system for vaccinated staff and are working on a tracking system.

A second list was provided on 05/04/22 that included all physicians and their vaccination status. A document titled "Breakdown of All Non-Contracted Staff and Physicians" listed 1846 vaccinated staff, nine staff members with medical exemptions, 123 staff members with religious exemptions, and three staff members with a temporary delay. A list of nine float pool nurses was provided. A list of Emergency Department float pool nurses and their vaccination status revealed the nine float pool nurses were not listed on the original list of staff.

A third list was provided that included six float pool staff that were granted religious exemptions and 21 float pool staff that were fully vaccinated for a total of 27 staff members.

Although the three separate lists of staff revealed a vaccination rate of 100 percent, there was not a comprehensive process for tracking all staff and their vaccination rate.

These facts were confirmed during interview with Staff B on 05/11/22 at 10:00 AM.

2. The facility policy titled Required Associate Immunization Program, effective 02/23/22, documented to mitigate the spread of COVID-19 for all personnel not fully vaccinated:

* Associates who have approved medical and religious exemptions from the vaccine are required to adhere to all recommended infection prevention guideline requirements.

* Associates exempt from receiving the COVID-19 vaccine are required to adhere to masking requirements even when the mask mandate is lifted.

* Medically and religiously exempted associates shall self-monitor for symptoms and stay home from work when experiencing COVID-19 related symptoms.

Staff B and Staff O were interviewed on 05/11/22 at 10:30 AM and asked to provide documentation of a contingency with additional procedures for unvaccinated staff to mitigate the transmission and spread of COVID-19. There was no documentation of additional procedures provided. It was confirmed that the procedures currently in place for unvaccinated staff to mitigate the transmission and spread of COVID-19 were no different from those of fully vaccinated staff members. It was confirmed that the policy lacked documentation of additional precautions for unvaccinated staff to mitigate the spread of COVID-19.