HospitalInspections.org

Based on staff interview and facility document review, it was determined that the facility failed to ensure that all staff were either fully vaccinated for COVID-19 or had an approved exemption or delay.

The findings included:

The surveyor reviewed the tracking log and documentation of the facility's staff. Two thousand five hundred and thirty-one (2531) out of two thousand five hundred and forty-six (2546) staff members (99.4%) were fully or partially vaccinated or exempt. Fifteen (15) or 0.6% of staff members are either unknown, partially vaccinated with second shot past due, or do not have an approved exemption or delay.

On 5/23/2022, the surveyor reviewed the COVID-19 staff vaccination numbers and policy with Staff Member (SM) #7. The surveyor discussed the seven (7) staff members who were past due for the second shot, SM #7 was unable to provide a plan or deadline of when those staff members were expected to receive the second shot. There were eight (8) listed in the log with no documentation; five (5) said "no record" or "no record provided" and three (3) said "recently hired with no record". SM #7 was unable to provide any additional for the eight (8).

At the exit conference on 5/25/2022, the findings were reviewed with SMs #1, #2, and #4.