HospitalInspections.org

Based on interview and record review, the facility failed to have a process for ensuring the implementation of additional precautions to mitigate the spread of COVID-19 for facility staff with COVID-19 vaccine exemptions. Findings include:

Review of the facility's policy, titled Mandatory Participation in COVID-19 Vaccination, last revised 1/18/22, showed:

- ..."11.0 Precautions, such as physical distancing and source control, intended to mitigate the transmission and spread of COVID-19 will be implemented for all HCP who have complied with this policy, but are not fully vaccinated for COVID-19,

- 12.0 The Hospital may implement measures to protect the safety and health of employees, patients, visitors, and other person from communicable diseases from HCPs who are not vaccinated. ..."

- The policy and procedure did not show any additional precautions for staff that were unvaccinated.

During an interview on 2/28/22 at 12:05 p.m., staff member N stated she performed staff observations for infection control practices and their compliance. Staff member N stated all staff are required to wear surgical masks and unvaccinated staff are not required to wear anything different, including an N95 mask. Staff member N stated she was not aware of any requirements for additional personal protective equipment (PPE) for unvaccinated staff.

During an interview on 2/28/22 at 2:37 p.m., staff member Q stated unvaccinated staff were not required to wear an N95 mask and/or be tested weekly for COVID-19.

During an interview on 3/1/22 at 8:32 a.m., staff member Q stated there were no additional precautions in place for unvaccinated staff members.