HospitalInspections.org

Based on interview and document review, the facility failed to develop and implement policy and procedures to ensure that all staff are fully vaccinated for COVID-19, potentially resulting in adverse outcomes for all 133 patients being treated at the facility.

Findings
Review of facility policy titled "COVID-19 Vaccination and Workplace Requirements, Revised 03/08/22, revealed that all staff were expected to be fully vaccinated or exempted by February 28, 2022. "All staff who provide services or work in facilities are required to be vaccinated, as per Schedule (a). Completed Vaccine Series will mean two-dose vaccines include: Pfizer-BioNTech or Moderna or vaccine authorized by the World Health Organization. The one-dose vaccine is: Johnson and Johnson / Janssen."

On 03/08/22 at 1325 during interview with Infection Prevention Nurse Staff G it was revealed that 335 of 343 staff were fully vaccinated. Review of document titled "Employee status of 2nd Dose as of 3-8-22" listed the names, job titles and vaccination status data. Staff G was queried if she was aware that all employees must be vaccinated by the February 28, 2022 according to the facility policy deadline. Staff G stated, "yes, they all are scheduled to complete their vaccinations in the next week." Staff G was further queried who is responsible for the vaccination data collection and monitoring. Staff G stated, "Staff Q is responsible."

On 03/09/22 at 1000 during interview with HR director Staff Q it was confirmed that eight unvaccinated employees (Staff I-Behavioral Health Tech (BHT), Staff J-Discharge Planning, Staff K- Registered Nurse (RN), Staff L-RN, Staff M-Therapist, Staff N-BHT, Staff O-Admissions assistant, Staff P-BHT) were currently working at the facility.