HospitalInspections.org

Based on interview and record review, the facility failed to have a process for ensuring the implementation of additional precautions to mitigate the spread of COVID-19, for facility staff with COVID-19 vaccine exemptions. Findings include:

Review of the facility's document, titled COVID-19 Vaccine, OHS 140, last revised 11/2021, was provided by the facility and showed:

- ..."... 5. If an exemption is granted, additional precautions may be implemented to minimize risk of transmission and spread of COVID-19, such as testing, physical distancing, or source control. Further, such additional precautions may be implemented if staff is not fully vaccinated. The hospital may implement measures to protect the safety and health of employees, patients, visitors, and other persons from communicable diseases from staff who are not vaccinated against COVID-19."

- For the staff who had been granted an exemption, the policy did not specify additional specific precautions that would be implemented to reduce the risk for COVID-19 transmission and exposure.

-The policy did not outline how the facility would monitor to ensure that additional precautions put in place were being implemented.

During an interview on 3/7/21 at 12:00 p.m., staff member A said, "Basically, we are not doing anything regarding exempt staff because of the differences in the guidance from CMS and CDC. CDC guidelines requires a 'well fitted mask.'"

Observations conducted throughout the survey showed all staff were wearing procedural (surgical type) masks at all times when conducting patient facing tasks, or when alone in their office. No other additional precautions were observed to be in place.