HospitalInspections.org

.
Based on document review, and interview the hospital failed to ensure 100% compliance with the infection control COVID-19 vaccination requirement. Specifically, the hospital failed to ensure all staff had either been fully vaccinated, or had an exemption or accommodation, as authorized by law, granted. Failure to meet the requirement may place staff and patients at greater risk for SARS-CoV-2 exposure and infection. Findings:

Review of the hospital vaccination status list, provided on 2/24/22 and 2/28/22, revealed a compliance rate of 97.8%. The list documented 1540 "colleagues" in total, 1506 have either been vaccinated, partially vaccinated, have an exemption or one pending. There were 34 with no record or missing documentation.


An interview on 2/24/22 at 1:44 PM, Case Manager #2, who was on the vaccination status list with "no record" confirmed he/she worked as a case manager and confirmed he/she had declined the vaccination and was in the process of submitting an exemption request. CM #2 also confirmed the facility had provided education on the vaccine during orientation and with the employee health nurse and through a newsletter. Further stating the hospital had offered the vaccine to him/her when hired.


An interview on 2/24/22 at 3:40 PM with Human Resource #1 (HR), responsible for tracking vaccination status of all hospital staff, confirmed the current rate of compliance was less than 100%. FS #1 stated there was a plan in place to achieve 100% compliance, to include the on-boarding process for new hires requiring vaccination or exemption; leadership conducting face to face conversations with staff daily to either complete the vaccination or request exemptions; emails and newsletters are utilized to ensure staff are notified.


During this interview the Director of Quality confirmed the facility was actively engaged in meeting the 100% compliance. Administration, department, and unit leaders are all involved working with staff to meet the requirement.


Observations on 2/23/22 and 2/24/22 throughout the facility revealed staff providing direct patient care and other staff wearing masks, performing hand hygiene.
.