HospitalInspections.org

Based on staff interview and review of CAH COVID-19 policies and administrative documents, it was determined the CAH failed to ensure 100% of staff received at least one dose of a COVID-19 single-dose vaccine, had a pending request for or have been granted an exemption, or had a temporary delayed vaccination. This had the potential to place CAH patients and staff at an increased risk of COVID-19 exposure. Findings include:

A CAH policy titled "COVID-19 Vaccination Policy," effective 1/18/22, stated, "Unless granted a medical or religious exemption ... By February 13, 2022, Staff must have received, at a minimum, the first dose of a primary series (Pfizer or Moderna) or a single dose (Johnson & Johnson) COVID-19 vaccine." This policy was not followed. An example includes:

The CAH's COVID-19 vaccine compliance tracking list was reviewed. The list included vaccine and exemption status for 1,024 employees. One employee was documented as "no vaccine or exemption."

The Infection Prevention Nurse was interviewed on 5/06/22 beginning at 10:25 AM. She confirmed 1 employee, who worked directly with patients, was not vaccinated and did not have an exemption. She stated the hospital had made multiple attempts to provide the employee with a vaccine and exemptions forms, and he has been informed his employment will be terminated on 3/14/22 if he remains noncompliant with the vaccine/exemption requirements. Additionally, she stated, the hospital has made sure the employee has been compliant with source control measures, including wearing an N95 mask in the hospital.

The CAH failed to ensure 100% of staff received at least one dose of a COVID-19 single-dose vaccine, had a pending request for or have been granted an exemption, or had a temporary delayed vaccination.