HospitalInspections.org

Based on observation, interview and document review, it was determined the hospital failed to ensure that all staff were fully vaccinated against COVID-19, partially vaccinated, granted an exemption to be vaccinated, or have a need for a temporary delay of vaccination (twenty (20) of the six hundred forty five (645) staff were affected).

The findings are:

During a complaint investigation at this site, a surveyor reviewed the hospital's compliance with the Omnibus Health Care Staff rule. On 6/6/22 a surveyor met with Staff Member #1 (SM#1) at 12:39pm and requested vaccine documentation on a sample of eighteen (18) HCA staff and two (2) contracted staff and a copy of the facility's COVID-19 vaccination policy and procedures. The surveyor received the sample on 6/7/22 at 9:15 am by Staff Member #10 (SM#10). It was found that four (4) out of the twenty (20) sampled records had no vaccination record on file. A review of the hospital's "COVID-19 Vaccination Requirements for Employees and Staff of HCA CMS Mandate Facilities" effective 1/2022 and authored by SM#10, found all required minimum components present.

A further review of the vaccination documentation found that of the six hundred forty five (645) facility employees, five hundred thirty (530) staff are fully vaccinated, sixteen (16) staff are partially vaccinated, seventy nine (79) staff are exempt and zero (0) staff are temporarily delayed. This results in ninety-seven percent (97%) compliance. During an interview, SM#10 stated that their contingency plan included contacting the employee to request a copy of an updated record. They stated that the facility had a "passive approach" to obtaining vaccination records. Employees were responsible to upload their record and exemption requests to a portal. SM#10 further added that non-vaccinated staff were required to mask up.