HospitalInspections.org

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Based on document review and interview, the hospital failed to have a process in place to verify and document vaccination or exemption status of agency staff.

Failure to verify and document vaccination or exemption status of contracted staff members risk unvaccinated staff providing patient care which could lead to patient, staff, or visitor infection and associated negative health outcomes.

Findings included:

1. Record review of the hospital policy titled, "COVID-19 Vaccination Policy," policy number KB0075454, reviewed 01/18/22, showed that all staff members must be fully vaccinated to work unless they are covered by an approved exemption. The policy defines workforce member as contractors and any individual working for the facility.

2. Record review of the exemption request form provided to Investigator #17 on 02/23/22 for Staff #1701 showed that a religious exemption request was submitted on 09/23/21. The hospital Caregiver Health department had not completed the status section of the form stating whether the request was approved or denied. On 02/24/22, the hospital provided subsequent documentation of an application for exemption from the contract agency that employed Staff #1701. Staff #1701 submitted the request on 09/28/21, but the agency had not documented a decision on this form at the time of review.

3. On 02/24/22 at 3:50 PM, Investigator #17 interviewed the Regional Director of Accreditation (Staff #1708) about the exemption process for contracted and agency staff. Staff #1708 stated that Staff #1701 worked at the facility from 09/05/21 to 01/01/22. Staff #1708 stated that the hospital had not received documentation form the agency and that it was working on getting information on agency staff members.

4. On 03/01/22, The Regional Director of Accreditation (Staff #1708) emailed Investigator #17 an approval form from the agency, with an approval date of 11/12/21. Staff #1708 stated that the hospital was working with the agency to ensure that all active staff across the healthcare system would have accurate records.