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ST NICHOLAS HOSPITAL
COVID-19 Vaccination of Facility Staff
Tag No.: A0792
Based on record review and interview the facility failed to follow their contingency plan for staff who are not fully vaccinated for COVID 19, in 1 of 1 COVID 19 Mandatory Vaccination policy.
Findings include:
A review of the facility policy "COVID 19 Vaccine Policy" last revision date of 4/14/2022 under Additional Measures for Unvaccinated Staff revealed such actions "may include...weekly testing...use a NIOSH (National Institute for Occupational Safety and Health) approved N95 or equivalent... for source control... regardless of whether they are providing direct care to or otherwise interacting with patients."
On 5/12/2022 at 3:35 PM during interview with Regulatory Quality Coordinator B and Director of Quality Q, when asked for the COVID test results of the unvaccinated staff chosen for review, Director Q stated unvaccinated staff were not required to do testing or wear N95's stating "we are not doing anything differently" from the vaccinated staff.
On 5/12/2022 at 3:41 PM during interview with Systems Director of Quality J, Director J stated the policy states that they "may" put extra precautions in place and confirmed "we are not treating them differently."