HospitalInspections.org

Based on interview, and record review, the facility failed to ensure unvaccinated staff adhered to additional precautions when providing direct patient care, and failed to specify what additional precautions were to be used by unvaccinated staff to mitigate the transmission of COVID-19 during direct patient care. This deficient practice had the potential to affect all patients in the hospital. Findings include:

Review of the facility's policy, titled COVID-19 Vaccination as a Condition of Employment, revised date of 4/22, showed:

- ...D. Exemptions and Accommodations,...

- 3. [facility] will take additional precautions intended to mitigate the transmission and spread of COVID-19 for all staff who are not fully vaccinated as necessary. Additional precautions currently in place are as follows: a. Universal masking procedures across the facility unless or until an employee is isolated in a room by themselves or while eating or drinking. b. Employees are required to document a physical temperature and attest to the absence of COVID-19 like symptoms prior to the start of each shift on site at [facility]...d. Other precautions have been implemented in the event of reasonable accommodation requests on an individual basis as appropriate.

- 4. At which time [facility] elected to adjust the requirement of universal masking precautions in the facility, employees who are not fully vaccinated will be required to continue with universal masking procedures in order to mitigate the spread of COVID-19

The policy did not show unvaccinated staff were to wear/implement additional precautions for direct patient care duties and staff were to perform the CDC recommended routine infection prevention and control practice of individual screening of symptoms.

During an interview on 4/27/22 at 1:12 p.m., staff members A and H stated all staff were to be screened prior to starting their shift. Staff member A stated the facility follows the Centers for Disease Control (CDC) recommendations regarding removal of universal precautions. Staff members A and H stated the facility had implemented universal control and all staff wear a well-fitting mask. Staff member A stated the facility did not implement any additional precautions for unvaccinated staff. Staff member A stated unvaccinated staff would be required to continue to wear a mask if/when the recommendation to relax universal masking. That would then be the facility's additional precautions. Staff member A stated the facility went with CDC guidance with a well-fitted mask for universal control. Staff member A stated the facility used a team approach to decide what precautions were to be used on unvaccinated staff. The team consisted of Infection Control, legal counsel and the Director of Human Resources. Staff member A stated the facility had not gone to weekly testing of unvaccinated staff.