HospitalInspections.org

Based on interview and record review, the facility failed to develop and implement additional infection control precautions for staff members who had been granted a medical, religious, or hardship exemption from COVID-19 vaccination. This deficient practice had the potential to increase the risk of COVID-19 spread to three current patients, all employees, volunteers, contracted staff, and visitors. Findings include:

Review of the facility policy, COVID-19 VACCINATION, OHS140, last revised 11/2021, showed, "... If an exemption is granted, additional precautions may be implemented to minimize the risk of transmission and spread of COVID-19, such as testing, physical distancing, or source control. Further, such additional precautions may be implemented if staff is not fully vaccinated. The hospital may implement measures to protect the safety and health of employees, patients, visitors, and other persons from communicable diseases from staff who are not vaccinated against COVID-19.

The policy did not show precautions that would actually be implemented, and at this time no additional precautions were being implemented in the facility for unvaccinated staff.

During an interview on 7/19/21 at 2:35 p.m., staff member B said the facility had been working on the development of a policy for the additional COVID-19 precautions that would be put in place for staff, contractors, and volunteers who had received an exemption from the vaccine mandate. She said the policy would contain precautions like requiring unvaccinated staff to wear an N-95 mask at all times, and to be tested for COVID-19 on a weekly basis. Staff member B said this policy was not in place at this time and had not been implemented. The current goal was to have these precautions in place by August 1st. Staff member A said they had planned to have these precautions in place at an earlier date, but they did not have the supplies or the staff available yet. Staff member A said the parent company wanted all the facilities to be uniform in their policies and they were still trying to assimilate into the processes of the new parent company.