HospitalInspections.org

Based on record review and interview, it was determined that the facility failed to obtain a physician order for a restraint for one (1) of five (5) patients sampled (Patient #2R).

Finding:

The hospital's policy titled "Use of Restraints" stated in part, "PROCEDURE 4) Obtain an order: A qualified LIP [Licensed Independent Practitioner] (an LIP who can treat the patient within his/her scope of practice) must give an order for restraint. The order may be given as a telephone order, which must be signed by the ordering LIP within 24 hours. An order for restraint may NOT be written as "PRN, Standing Order or Protocol". The order for restraint must include the following: a) type of restraint, b) reason for restraint, c) start time (if known), and d) criteria for release."

Documentation in Patient #2R's record by nursing staff indicated the patient was restrained on 2/2/2021 from 8:29 PM to 9:51 PM. There was no evidence in the patient's record of an order for this restraint.

On 2/16/2022 at 11:30 AM, the Patient Care Director of Pediatrics confirmed there was no order written for this restraint.

On 2/16/2022 at 12:09 PM, the Chief Medical Officer confirmed there was no order written by a LIP for this restraint.

Based on policy review and interviews, the hospital failed to ensure policies and procedures addressed a process for tracking and documenting the Coronavirus 2019 ("COVID-19") vaccination status of any staff who had obtained any booster doses as recommended by the Federal Center for Disease Control and Prevention ("CDC"). In addition, the hospital failed to ensure their policies and procedures addressed the confirmation of recognized clinical contraindications to COVID-19 vaccines, as indicated by Federal CDC, before granting medical exemptions.

Findings:

1. A review of the Northern Lights Health, "SARS-CoV2 Workforce Member Vaccination Policy," dated 2/16/2022, did not address a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

On 2/16/2022 at 11:00 AM, the Associate Vice President of Infection Prevention confirmed the Northern Lights Health, "SARS-CoV2 Workforce Member Vaccination Policy," did not address a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

On 2/22/2022 at 5:15 PM, the Chief People Officer, stated, the Medical Exemption Committee uses the State Law for Guidance. He confirms the hospital vaccine policy did not include a procedure that addressed a process for tracking and documenting the COVID-19 vaccination status of any staff who had obtained any booster doses as recommended by the CDC.

2. The Northern Light Health's "SARS-CoV2 Workforce Member Vaccination Policy," dated 2/16/2022, did not include a process of how the hospital would confirm the submitted medical exemption documentation was a recognized clinical contraindication to the COVID-19 vaccine, as indicated by the Federal CDC, before granting medical exemptions. It was noted that the policy indicated the reference at the end of the policy was the Maine CDC rules. The Maine CDC rules and the Federal requirements are different in relation to medical exemptions. The Maine rules allows Provider to make a determination based on his/her professional judgement and the Federal requirements require documentation of recognized clinical contraindications to the COVID-19 vaccine.

On 2/16/2022 at 12:53 PM, the Associate Vice President of Infection Prevention confirmed the Northern Light Health, "SARS-CoV2 Workforce Member Vaccination Policy," did not include a procedure for the review of medical exemptions to ensure the reason specified by the provider was a recognized clinical contraindication for COVID-19 vaccination as determined by the CDC.

On 2/22/2022 at 12:00 PM, Physician #1, who was a member of the Advisory Group for Medical Exemptions, stated he was not aware if the hospital vaccine policy had a written procedure to determine the reasons given by the Provider signing the exemption request was a recognized clinical contraindication to COVID-19 vaccination; they receive the request through Human Resources and Work Health; they collect the requests that are signed by the Licensed Practitioner; the requests are brought to the Advisory Group; and they discuss the reasons given by the Provider for the medical exemption. They use the CDC/Advisory Committee on Immunization website put up in August or September 2021 when the hospital convened medical experts to review medical exemptions.

On 2/22/2022 at 4:45 PM, Physician #2, who is a member of the Adhoc Committee for Medical Exemptions, stated he was not aware if the hospital vaccine policy had a written procedure for medical exemptions reviews for the Provider's reasons for exemption for the Medical Exemption Committee; the process is the staff completes a request; the staff's personal Licensed Practitioner signs it; and members of the committee meet to review the requests following the CDC Guidance.

On 2/22/2022 at 5:15 PM, the Chief People Officer, stated, the Medical Exemption Committee only uses the State law for guidance; he confirmed the hospital vaccine policy did not include a procedure for how the medical exemption committee determines if the reason given in the request by the Provider signing the exemption is valid; and the Committee felt the State guidance was more stringent because it did not allow for religious exemptions.