HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the hospital staff developed and implemented a system to allow the hospital staff to identify if all members of 1 of 1 Medical Staff at the hospital had either completed their COVID-19 vaccination or had received an approved exemption instead of receiving the COVID-19 vaccine. Failure to identify if a staff member was either fully vaccinated or if the staff member had an approved exemption could potentially result in the hospital staff allowing an unvaccinated staff member to not implement additional precautions to prevent the spread of COVID-19. The hospital's administrative staff identified a census of 116 inpatients at the start of the survey.

Findings include:

1. Review of the policy "COVID-19 Health Care Staff Vaccination", last revised 05/2022, revealed in part..."All Colleagues are required to receive a COVID-19 vaccination, and any subsequent booster vaccinations within the vaccination time frames established by MercyOne ... Colleagues may request a religious or medical exemption. Colleagues who are unable to furnish proper exemption documentation must be vaccinated."

Colleagues refers to "individuals who provide any care, treatment, or other services for the [acute care hospital] and/or its patients, including employees; licensed practitioners; ... and individuals who provide care, treatment, or other services for the facility and/or its patients, under contract or other arrangement. This also includes individuals under contract or arrangement with the facility, including ... licensed practitioners [such as physicians, advanced registered nurse practitioners, and physician's assistants] ..."


2. Review of the hospital's COVID-19 vaccination tracking documents for all colleagues revealed that 142 physicians and other licensed practitioners had signed an attestation document regarding if they had received the COVID-19 vaccination. Further review of the attestation document revealed that the licensed practitioner attested "I attest as [licensed practitioner's name] that I confirm that I have completed COVID-19 vaccination or have an approved exemption in accordance with the requirement."


3. During an interview on 5/26/22 at 3:00 PM, the Vice President of Quality and Integration acknowledged that if a licensed practitioner signed the attestation form affirmatively, the hospital staff would not know if the licensed practitioner had received the COVID-19 vaccination or if the licensed practitioner had an approved exemption. The Vice President of Quality and Integration further revealed that the licensed practitioners had not utilized the hospital's process to apply for an approved exemption to the COVID-19 vaccination requirement. Thus, the hospital staff did not know who had approved the licensed practitioner's exemption request to the COVID-19 vaccination requirement or if the exemption met the hospital's requirements for an approved COVID-19 vaccine exemption.