HospitalInspections.org

Based on document review and interview the facility failed to ensure protection of patient rights related to the right of patients and/or family members to participate in their treatment/plan of care in 6 of 30 (N1, N2, N3, N6, N9, N10) closed/open medical records (MR) reviewed:

Findings include:

1. Policy/procedure 702.25, Treatment Team Protocol, revised/reviewed 2/18 indicated: Page 2: "The patient and family shall have input into setting the objectives of hospitalization during the psychiatric evaluation and psychosocial assessment process. d) Once the Master Treatment Plan has been formulated, the plan shall be reviewed with the patient and/or family by the Mental Health Clinician either individually or in family session. Efforts shall be made by the Mental Health Clinician to obtain both patient and family signatures, although verbal discussion can be documented in the signature area as having been reviewed in instances the family cannot physically come to the facility. Additional efforts to involve the patient/family in treatment plan development/implementation or to obtain signatures should be documented in the progress notes of patient chart and on the Master Treatment Plan itself.

2. Policy/procedure 704.06, Right of Family/Guardian to Participate in Treatment, revised/reviewed 1/18 indicated: "Clinical Services staff are responsible for: arrangements for the family's involvement with the treatment. Ensuring family participation, involvement and acknowledgment of treatment plan. Facilitating family therapy and guardian participation in treatment.

3. Review of patients' N1, N2, N3, N6, N9 and N10's MRs lacked documentation of patient and/or family participation in the planning and/or updating of the above-mentioned patients' Master Treatment Plans.

4. On 11/13/18 at approximately 1430 hours, staff P1 (Director of Nursing) was interviewed and confirmed the facility is not documenting patient and/or family participation in the development and of the patient's Master Treatment Plan.

Based on document review and interview, the hospital failed to ensure the Quality Assurance Performance Improvement (QAPI) program, 1. used data to monitor the effectiveness and safety of services and quality of care for 10 of 29 services and functions (Biomedical engineering, biohazard waste, employee health injuries, housekeeping, maintenance, outpatient services, psychology services, telepsychology/psychiatry services, response to patient emergencies, and security) and 2. specified the frequency and detail of data collection for 9 of 29 monitors (Chemical dependency program, laboratory services, laundry, medication errors, pharmacy, social services, transcription, utilization review and patient grievances).

Findings include:

1. Review of the Performance Improvement Plan 2018, Revision effective October 2018, indicated the following:
A. INTRODUCTION: The Program for Performance Improvement (PI)...involves a planned systematic, organization-wide approach to process, design and performance measurement, analysis and improvement.
B. PURPOSE: 3. Collecting data to monitor the stability of existing processes, identify opportunities for improvement, and identify changes that will lead to improvement and sustain improvement.
C. DESIGN: 2. Develop a systematic method to determine the process' effect on the organization's vision, mission, plans...
D. MEASUREMENT/MONITORING: (The hospital) uses a systemic collection of quantifiable data about both processes and outcomes over time or at a single pint in time. In order to improve organizational performance, it is essential that observable, quantifiable information (i.e. statistical data) is utilized...
E. ASSESSMENT/ANALYSIS: 5. Quality control includes: a) Defined criteria for data capture, data input, and recording; b) Use of appropriate sampling...6. Validity and verification of data is done with logs to support data...

2. Review of PI meeting minutes dated 10/22/18, 9/19/18, 8/15/18, 7/23/18, 6/28/18, 5/16/18, 4/18/18, 3/21/18 and 1/17/18, lacked documentation of the committee having established or reviewed data for the monitors of biomedical engineering, biohazard waste, employee health injuries, housekeeping, maintenance, outpatient services, psychology services, telepsychology/psychiatry services, response to patient emergencies, and security and lacked documentation of the frequency and detail of data collection for monitoring the following: Chemical dependency program, laboratory services, laundry, medication errors, pharmacy, social services, transcription, utilization review and patient grievances.

3. Review of facility QAPI documentation of established monitors and data collected lacked documentation of data collection for biomedical engineering, biohazard waste, employee health injuries, housekeeping, maintenance, outpatient services, psychology services, telepsychology/psychiatry services, response to patient emergencies, and security and lacked documentation of the frequency and detail of data collection for monitoring the following: Chemical dependency program, laboratory services, laundry, medication errors, pharmacy, social services, transcription, utilization review and patient grievances.

4. On 11/14/18 between approximately 1:00 p.m. and 3:30 p.m., A3, Performance Improvement Manager, verified the PI program did not have documentation of the following:
A. Having monitored data for the services/functions of biomedical engineering, biohazard waste, employee health injuries, housekeeping, maintenance, outpatient services, psychology services, telepsychology/psychiatry services, response to patient emergencies, and security;
B. Specified frequency and detail of data collection for monitoring the following: Chemical dependency program, laboratory services, laundry, medication errors, pharmacy, social services, transcription, utilization review and patient grievances.

Based on document review and interview, medical staff (MS) failed to examine credentials of candidates for MS membership and make recommendations to the governing body on the appointment of 2 of 4 in-house physician MS members (MD1, MD3) and 1 of 1 telemedicine physicians (MD6) for MS membership in accordance with their bylaws (see tag 341), failed to ensure the majority of the Medical Executive Committee (MEC) of the Medical Staff (MS) were doctors of medicine or osteopathy and failed to ensure the MEC was established in accordance with their Bylaws in one facility (see tag 347), and failed to ensure the majority of the Medical Executive Committee (MEC) of the Medical Staff (MS) were doctors of medicine or osteopathy and failed to ensure the MEC was established in accordance with their Bylaws in one facility (see tag 353).

The cumulative effects of the above resulted in the hospitals failure to have an organized medical staff operating under its bylaws with responsibility for the quality of medical care provided to patients by the hospital.

Based on document review and interview, medical staff (MS) failed to examine credentials of candidates for MS membership and make recommendations to the governing body on the appointment of 2 of 4 in-house physician MS members (MD1, MD3) and 1 of 1 telemedicine physicians (MD6) for MS membership in accordance with their bylaws.

Findings include:

1. Review of MS Bylaws, reviewed October 29, 2018, indicated the following:
A. Article 4 - CATEGORIES OF THE MEDICAL STAFF AND RESIDENTS AND INTERNS. 4.2 Qualifications. 4.2.1 The Active Staff shall consist of Members, each of whom:
i. (b) resides and practices close enough to the Facility's program to provide continuous and timely care to and supervision of their patients or to arrange a suitable alternative for such care and supervision.
ii. (c) is regularly involved in the care of patient in the Facility's programs. "Regularly involved,"...means admitting a sufficient number of inpatients or outpatients...to enable the MS and the Facility to assess the quality of patient care provided by the Member and to assure that the Member is sufficiently involved in Facility and MS activities to hold office and vote on MS issues in an informed manner. Unless otherwise determined by the Board, this shall mean admitting the equivalent of ___ (this was blank) inpatients each MS year. (The Bylaws lacked documentation of a number of required admissions for Active staff membership.)
B. Article 6.2 - APPLICATION FOR INITIAL APPOINTMENT. 6.2.2 Content. The application form shall include but not be limited to:
i. (b) specific request stating the appointment status and Clinical Privileges for which the applicant wishes to be considered.
ii. (i) for all new applicants and practitioners requesting new or additional privileges, evidence of the practitioner's professional practice review, volumes and outcomes from organization(s) that currently privilege the applicant...
C. Article 6.4 - PROCESSING THE APPLICATION. 6.4.2 Appointment Considerations. Each recommendation concerning the appointment of a staff member and/or for clinical privileges to be granted shall be based upon an evidence-based assessment of the applicant's experience, ability, and current competence by the Credential Committee, MEC (Medical Executive Committee) and Board, including assessment of the applicant's proficiency in the following areas: (a) Patient Care... (b) Medical/Clinical Knowledge... (c) Practice-Based Learning and Improvement... (d) Interpersonal and Communication Skills... (e) Professional behaviors... (f) Systems-Based Practice...
i. 6.4.4 Review by the MEC. The MEC shall review and analyze all relevant information regarding the requesting practitioner's current licensure status, training, experience, current competence, and ability to perform the requested privileges...
ii. 6.4.5 MEC Action. After the MEC has completed its review, the MEC shall then forward to the Board the application, related documentation, relevant information, and a written report and recommendation as to status, membership, Clinical Privileges, and any special conditions.
D. Article 6.7 - REAPPOINTMENT PROCESS. 6.7.3 Content of the Reappointment/Re-credentialing Application Form. The Reappointment/Re-credentialing Application Form...when completed, shall contain information necessary to maintain, as current, the MS's file including, without limitation, the following information about:
i. (b) evidence of the individual's support of the MS and Facility through, for example, medical record delinquency status, meeting attendance, committee service, satisfaction of minimum patient care requirements to maintain Staff category, and compliance...
ii. 6.7.6 MEC Review. The MEC shall review and analyze all relevant information regarding the requesting practitioner's current licensure status, training, experience, current competence, and ability to perform the requested privileges...
iii. 6.4.5 MEC Action. After the MEC has completed its review, the MEC shall then forward to the Board the application, related documentation, relevant information, and a written report and recommendation as to status, membership, Clinical Privileges, and any special conditions.
E. Article 6.10 - TELEMEDICINE. Practitioners who provide health care services by means of electronic technology to Facility's patients shall not provide such services without first being granted Clinical Privileges. Application for Clinical Privileges shall be made as provided in these Bylaws, except that such privileges may be granted based on credible documented evidence that the Member enjoys the same or similar privileges at a hospital that is accredited by The Joint Commission.
F. Article 7.2 DELINEATION OF PRIVILEGES IN GENERAL. 7.2.2 Basis for Privileges Determinations. Requests for Clinical Privileges shall be evaluated on the basis of the Member's, or AHP's education; course work; training; treatment results; experience; character; peer recommendations; and demonstrated judgment and ability to provide, with reasonable accommodation, safe an competent care; and physical, mental and emotional capability, as related to the performance of the Privileges requested.

2. Review of MS/AHP (Medical Staff/Allied Health Professional) credential files indicated the following:
A. MD1 was reappointed as an Active MS member and granted privileges on 8/30/18. The credential file lacked documentation of:
i. Medical record delinquency status, meeting attendance, committee service, and satisfaction of patient care requirements for staff category.
ii. MD1's treatment results; character; peer recommendations; demonstrated judgment and ability to provide safe and competent care as related to the performance of the Privileges requested.
iii. MS, MEC or Credential Committee review and recommendation(s) for appointment status and/or privileging.
B. MD3 was an initial appointment to the Courtesy staff and granted privileges on 7/25/18. The credential file lacked documentation of:
i. MD3 having completed residency and/or evidence of the practitioner's professional practice review, volumes and outcomes from organization(s) that currently privilege the applicant...
ii. MD3's treatment results; character; peer recommendations; demonstrated judgment and ability to provide safe and competent care as related to the performance of the Privileges requested.
iii. MS, MEC or Credential Committee review and recommendation(s) for appointment status and/or privileging.
C. MD6 was an initial appointment to the MS and granted privileges on 3/9/17. Privileges requested and approved included, but was not limited to, Telemedicine. The credential file lacked documentation of:
i. The category of MS to which MD6 was appointed.
ii. Evidence of the practitioner's professional practice review, volumes and outcomes from organization(s) that currently privilege the applicant...
iii. Documentation that Member enjoyed the same or similar privileges at a hospital that was accredited by The Joint Commission as required by the Bylaws.

3. Review of facility documents lacked documentation of a Credential Committee.

4. Review of MS/MEC meeting minutes dated 12/21/17, 1/23/18, 2/27/18, 3/27/18, 4/24/18, 5/22/18, 6/28/18, 7/3/18, 7/26/18, 8/30/18, 9/25/18, 9/27/18, 10/31/18 and 11/7/18 lacked documentation of MS, MEC or Credential Committee review and recommendation(s) for appointment status and/or privileging for MD1 and MD3.

5. Review of the documents titled Psychiatrist 2018 Profile Data and B Tag Audit Compliance Rates lacked documentation of number of inpatients or outpatients to which care was provided by any Member and lacked documentation of physician involvement in Facility and MS activities.

6. On 11/15/18 between approximately 12:00 p.m. and 1:00 p.m., A4, Human Resources and Risk Management Director, confirmed the following:
A. He/She verified the hospital did not have a "Credential Committee", did not have documentation of MS/MEC recommendation of appointment/reappointments for MD1 and MD3.
B. A4 verified the MS Bylaws omitted documentation of a blank for the number of admissions required for MS applicants to qualify for Active Staff membership and that MD1 had been approved by the governing body for Active staff membership without recommendation by the MS/MEC and granted privileges without documentation of treatment results and performance related to privileges requested.
C. He/She verified MD3 had not yet completed residency and the file lacked evidence of the practitioner's professional practice review, volumes and outcomes from organization(s) that currently privilege the applicant.
D. A4 verified the credential file for MD6 lacked documentation of the MS category to which he/she was appointed.
E. He/She verified the file for MD6 lacked documentation of professional practice review with volumes and outcomes from organization(s) that currently privilege the applicant.
F. A4 indicated that MD6 was an "Active" "Telemedicine" MS member.
G. A4 verified the file for MD6 lacked documentation of MD6 having the same or similar privileges at a hospital that was accredited by The Joint Commission as required by the Bylaws.

Based on document review and interview, the hospital failed to ensure the majority of the Medical Executive Committee (MEC) of the Medical Staff (MS) were doctors of medicine or osteopathy and failed to ensure the MEC was established in accordance with their Bylaws in one facility.

Findings include:

1. Review of MS Bylaws, reviewed October 29, 2018, indicated the following in Article 11 - COMMITTEES AND FUNCTIONS: 11.2.1 Composition. MEC shall consist of Members, a majority of who shall be fully licensed physician Members of the Active Staff. The Medical Director shall be a member and chairman of the MEC. The CEO (Chief Executive Officer) shall attend every meeting of the MEC or shall send a designee in their stead. The remaining Members of the Committee shall be: (a) the President of the Staff; (b) the Vice President of the Staff (if any); (c) the Secretary-Treasurer of the Staff; and (d) up to three (3) Members of the Active Staff who are elected by the Staff to serve on the MEC for (1) year...

2. Review of the document titled Committees: 2018 indicated the MEC to be composed of 7 members as follows: 1. MD1 (Physician) 2. MD5 (Psychiatrist) 3. MD6 (Psychiatrist) 4. A1 (CEO) 5. A9 (Chief Nursing Officer/CNO) 6. A4 (Human Resources and Risk Management Director) 7. A3 (Performance Improvement Manager)

3. Review of MEC meeting minutes dated 12/21/17, 1/23/18, 2/27/18, 3/27/18, 4/24/18, 5/22/18, 6/28/18, 7/3/18, 7/26/18, 8/30/18, 9/25/18, 9/27/18, 10/31/18 and 11/7/18 lacked documentation of functions/responsibilities of the MEC being performed by a majority of MS doctors as follows:
A. On 4/24/18, a motion was made by A8, Director of Clinical Services, for appointment/re-appointment of a Family Nurse Practitioner (FNP) to the MS and was seconded by AH1, Clinical Nurse Specialist.
B. On 4/24/18, AH1 made a motion and A8 seconded the motion for re-appointment of MD5.
C. On 4/24/18, MD5 made a motion and AH1 seconded the motion for re-appointment of a physician.
D. On 11/7/18, A1 made a motion to appoint MD1 as providing oversight of Assessment and Referral. The minutes indicated the motion was seconded by the "Medical Executive Committee". MEC members indicated to have been present lacked documentation of a quorum of members from the MEC and the minutes lacked documentation of any physician/MS member present other than MD1.

4. On 11/15/18, between approximately 11:00 a.m. and 11:30 a.m., A1 verified the MEC was not composed of a majority of doctors or members as described in the MS Bylaws. A1 also confirmed that motions/votes had been made by non-MEC/non-MS staff personnel.

Based on document review and interview, the hospital failed to ensure the majority of the Medical Executive Committee (MEC) of the Medical Staff (MS) were doctors of medicine or osteopathy and failed to ensure the MEC was established in accordance with their Bylaws in one facility.

Findings include:

1. Review of MS Bylaws, reviewed October 29, 2018, indicated the following in Article 11 - COMMITTEES AND FUNCTIONS: 11.2.1 Composition. MEC shall consist of Members, a majority of who shall be fully licensed physician Members of the Active Staff. The Medical Director shall be a member and chairman of the MEC. The CEO (Chief Executive Officer) shall attend every meeting of the MEC or shall send a designee in their stead. The remaining Members of the Committee shall be: (a) the President of the Staff; (b) the Vice President of the Staff (if any); (c) the Secretary-Treasurer of the Staff; and (d) up to three (3) Members of the Active Staff who are elected by the Staff to serve on the MEC for (1) year...

2. Review of the document titled Committees: 2018 indicated the MEC to be composed of 7 members as follows: 1. MD1 (Physician) 2. MD5 (Psychiatrist) 3. MD6 (Psychiatrist) 4. A1 (CEO) 5. A9 (Chief Nursing Officer/CNO) 6. A4 (Human Resources and Risk Management Director) 7. A3 (Performance Improvement Manager)

3. Review of MEC meeting minutes dated 12/21/17, 1/23/18, 2/27/18, 3/27/18, 4/24/18, 5/22/18, 6/28/18, 7/3/18, 7/26/18, 8/30/18, 9/25/18, 9/27/18, 10/31/18 and 11/7/18 lacked documentation of functions/responsibilities of the MEC being performed by a majority of MS doctors as follows:
A. On 4/24/18, a motion was made by A8, Director of Clinical Services, for appointment/re-appointment of a Family Nurse Practitioner (FNP) to the MS and was seconded by AH1, Clinical Nurse Specialist.
B. On 4/24/18, AH1 made a motion and A8 seconded the motion for re-appointment of MD5.
C. On 4/24/18, MD5 made a motion and AH1 seconded the motion for re-appointment of a physician.
D. On 11/7/18, A1 made a motion to appoint MD1 as providing oversight of Assessment and Referral. The minutes indicated the motion was seconded by the "Medical Executive Committee". MEC members indicated to have been present lacked documentation of a quorum of members from the MEC and the minutes lacked documentation of any physician/MS member present other than MD1.

4. On 11/15/18, between approximately 11:00 a.m. and 11:30 a.m., A1 verified the MEC was not composed of a majority of doctors or members as described in the MS Bylaws. A1 also confirmed that motions/votes had been made by non-MEC/non-MS staff personnel.

Based on document review and interview the facility failed to ensure staff develop care plans which include goals/interventions for each patient problem identified by the treatment team for each patient in 9 of 30 (N1, N2, N3, N5, N6, N7, N21, N22, N24) medical records (MR) reviewed:

Findings include:

1. Policy/procedure 702.25, Treatment Team Protocol, revised/reviewed 2/18 indicated on page 3: "Each discipline will formulate goals/interventions for each problem identified by the treatment team. This includes Physician/Designee, Nurse, Therapist/Counselor, Art Therapy, and Recreation Therapy".

2. Review of patients N1, N2, N3, N5, N6, N7, N21, N22 and N24 MR's indicated facility staff failed to develop complete patient care plans for each of the above-mentioned patients by failing to document goals/interventions for each patient problem identified by the treatment team.

3. On 11/13/18 at approximately 1430 hours, staff P1 (Director of Nursing) was interviewed and confirmed the facility did not develop complete patient Master Treatment Plans for the above-mentioned patients by failing to document goals/interventions for each patient problem identified by the treatment team. Staff P1 confirmed staff are not following policy/procedure for treatment planning.

Based on record review, observation and interview; the facility failed to ensure 6 of 6 hospital corridors were provided with a complete interior finish with a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. LSC 10.2.3.4 states products required to be tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials shall be grouped in the following classes in accordance with their flame spread and smoke development.
(a) Class A Interior Wall and Ceiling Finish. Flame spread 0-25; smoke development 0-450. Includes any material classified at 25 or less on the flame spread test scale and 450 or less on the smoke test scale. Any element thereof, when so tested, shall not continue to propagate fire.
(b) Class B Interior Wall and Ceiling Finish. Flame spread 26-75; smoke development 0-450. Includes any material classified at more than 25 but not more than 75 on the flame spread test scale and 450 or less on the smoke test scale.
(c) Class C Interior Wall and Ceiling Finish. Flame spread 76-200; smoke development 0-450. Includes any material classified at more than 75 but not more than 200 on the flame spread test scale and 450 or less on the smoke test scale (see K tag 331), failed to ensure 1 of over 100 sprinklers in the facility were installed in accordance with the requirements of NFPA 13, Standard for the Installation of Sprinkler Systems. NFPA 13, 2010 edition, at 9.2.3.5.1 states the cumulative horizontal length of an unsupported armover to a sprinkler, sprinkler drop, or sprig-up shall not exceed 24 inches for steel pipe or 12 inches for copper tube (see K tag 351), failed to provide complete documentation for fire drills conducted on the first, second and third shift for 4 of 4 quarters (see K tag 712).
.

Findings include:

1. Based on record review with the Director of Plant Operations (DPO) from 9:45 a.m. to 2:45 p.m. on 11/14/18, interior finish flame spread rating documentation was not available for review. Based on observations with the DPO during a tour of the facility from 2:45 p.m. to 4:00 p.m. on 11/14/18, paneling was installed on the walls in all corridors of the hospital, excluding the main entrance and office areas, from the floor to the ceiling. Based on interview at the time of the observations, the DPO stated the paneling is called FRP board, it is not treated with flame retardant materials by hospital staff, he was not aware of the flame spread for the interior finish and agreed flame spread rating documentation for the FRP board was not available for review at the time of the survey.

2. Based on observations with the Director of Plant Operations (DPO) during a tour of the facility from 2:45 p.m. to 4:00 p.m. on 11/14/18, the four foot horizontal length of steel sprinkler pipe which is an armover to a sprinkler was unsupported near the ceiling in the foyer for the main entrance lobby. Based on interview at the time of the observations, the DPO agreed the four foot horizontal length of steel sprinkler pipe armover to a sprinkler was unsupported in the aforementioned area.

3. Based on review of "Fire Drill Report" documentation with the Director of Plant Operations (DPO) during record review from 9:45 a.m. to 2:45 p.m. on 11/14/18, documentation for fire drills conducted on:
a. the first shift on 02/13/18 at 10 a.m., on 05/08/18 at 2:00 p.m., on 09/05/18 at 7:30 a.m. and on 10/19/18 at 12:30 p.m.
b. the second shift on 11/02/17 at 3:13 p.m., 01/05/18 at 8:57 p.m., 04/20/18 at 4:30 p.m. and on 07/18/18 at 6:30 p.m.
c. the third shift on 12/27/17 at 11:16 p.m., on 03/20/18 at 4:00 a.m., 06/14/18 at 1:00 a.m. and on 08/15/18 at 6:00 a.m.
did not include documentation of staff who participated in the drill. In addition, review of fire drill procedures in "Emergency Operations Plan" documentation stated "A sign in sheet shall be used to record the names of all respondents to the drill. This sign in sheet shall be attached to the fire drill critique form." Based on interview at the time of record review, the DPO stated it's too hectic at the time of the drill to obtain and record signatures as staff are usually trying to make sure patients are calm and their needs are being met but agreed fire drill documentation for all shifts for the most recent twelve month period did not include staff who participated in the drill.

Based on document review and interview, the hospital failed to ensure the infection control officer developed a system for identifying and controlling communicable diseases of personnel in accordance with the Centers for Disease Control and Prevention (CDC) guidelines for 4 of 4 employees (P2, P3, P4 and P5).

Findings include:

1. Review of the policy titled Employee Health Program Description, Last Review Date 1/18, indicated the following:
A. All employees will undergo a pre-employment health screening that includes: Pre-employment health history and inventory relative to significant past and current infections, injuries and conditions predisposing to them (sic) including history for: Tetanus/Diphtheria, Polio, Rubella, Measles, Mumps, Hepatitis B and Varicella.
B. The employee will have the following screening tests: "TB skin test" (Mantoux technique) and/or "PA chest x-ray" if previous history of positive. Any test required by state or local health departments.
C. If not addressed in hospital policies, the "CDC guidelines" will be the reference guide for prophylaxis and management...

2. Review of personnel files for P2, P3, P4 and P5 lacked documented evidence of disease immunity to tetanus/Diphtheria, Polio, Rubella, Measles, Mumps, Hepatitis B or Varicella and lacked documentation of each having had two-step baseline tuberculosis screen testing upon hire.

3. On 11/15/18 between approximately 2:00 p.m. and 2:30 p.m., A4, Human Resources and Risk Management Director, indicated the following:
A. Employee indication of immunization is by self-attestation and immunity to communicable diseases is not verified.
B. Employee P4, housekeeper, indicated s/he had no records of immunization/immunity to Hepatitis A, Hepatitis B, Mumps, Measles/Rubeola, Rubella, Chicken Pox/Varicella, Pertussis/Whooping Cough or Tetanus as listed on their form. A4 indicated the employee was adopted from another country and did not have any documentation of immunizations or immunity.
C. A4 also verified the hospital does not perform 2-step tuberculin baseline testing of new employees.