HospitalInspections.org

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Based on interview and document review, the hospital (1) failed to develop a process for review and approval of non-medical accommodation requests for 6 of 6 requests reviewed (Staff #11, 12, 13, 14, 15, 16), (2) failed to ensure that medical accommodation requests complied with the Federal Covid-19 vaccine mandate for 3 of 4 staff requests reviewed (Staff #11, 12, 17), (3) failed to ensure that exempt, unvaccinated staff complied with additional precautions to mitigate the spread of Covid-19 for 2 of 5 unvaccinated staff observed (Staff #3, #5), and (4) failed to implement and maintain a tracking system for expiration of temporary exemptions.

Failure to develop and implement policies and procedures to ensure that the hospital has a standardized method for evaluating and securely documenting accommodations for Covid -19 vaccination, failure to ensure compliance with additional precautions to mitigate the spread of Covid-19, and failure to implement and maintain a tracking system for expiration of temporary exemptions, places patients, visitors, staff, and the community at risk for illness, disability, and death.

Findings included:

Item #1 Non-medical Accommodations

1. Review of the document titled, "Request for Accommodation - Religious Exemption," revision 4, dated 08/18/21, showed subheadings of:

a. Describe specific accommodation requests and document interactive process
b. Describe why accommodation is denied (if direct threat or undue hardship, specifically describe)
c. If the requested accommodation is denied, what are some alternative accommodations (list in order of preference)
d. Date discussed with employee
e. Final accommodation agreed upon
f. If no agreement on accommodation, describe the interactive process with the employee.

2. Review of 6 documents titled, "Request for Accommodations - Religious Exemption," page 2, submitted by staff, showed that sections a-f were blank.

3. On 03/17/22 at 2:30 PM, an interview with a Senior Human Resources (HR) Generalist (Staff #1) showed that the process for requesting religious accommodation required that:

a. the staff member requesting accommodation must submit the form titled, "Request for Accommodation-Religious Exemption". The submission must include a statement regarding how the individual's religious beliefs conflicted with obtaining a Covid-19 vaccination.
b. Requests were forwarded to the Executive Committee for evaluation and approval or denial and returned to HR for staff notification.

4. On 03/17/22 at 2:30 PM, an interview with Staff #1 confirmed that page 2 of 6 staff Requests for Accommodation -Religious Exemption forms was blank. Staff #1 was unsure of what criteria the Executive Committee used to approve or deny requests for religious accommodation.

5. Review of the policies titled, "Exposure Control Plan (Covid-19)," revised 11/05/21, and "Covid-19 Emergency Temporary Standard (ETS) Exemption Policy," no policy number, effective 07/30/21, showed that neither policy contained information regarding the religious exemption evaluation and approval process.


Item #2 Medical Accommodations

1. Review of the document titled, "Request for Accommodation -Medical Exemption," revision 4, dated 08/18/21, showed subheadings of:

a. Employee Information
b. Medical Exemption:(to be completed by a qualified healthcare provider) with choices of:
i. severe allergic reaction
ii immediate allergic reaction of any severity to a previous dose or diagnosed allergy to a component of the vaccine
iii. Other medical circumstance preventing vaccination with any available vaccine
c. HR [Human Resources] Use only: Accommodation request approved or denied with specific accommodation details or the reason why the accommodation was denied.

2. Review of 3 forms titled, "Request for Accommodation-Medical Exemption" showed:

a. The form submitted by Staff #11 requested a temporary accommodation. There was no provider statement or signature and no HR information that showed approval or denial.
b. The form submitted by Staff #12 requested a temporary accommodation. The HR documentation on Page 2 where approval or denial should be documented was missing.
c. The form submitted by Staff #17 had a signature in the provider section with no credential indicated.

3. On 03/17/22 at 1:00PM, an interview with a Human Resources Generalist(Staff #1) showed that the process for staff to obtain a medical accommodation was to:

a. submit a completed "Request for Accommodation-Medical Exemption" form
b. request review by the Chief Nursing Officer
c. Final review and acceptance or denial by the Chief Medical Officer

4. On 03/17/22 at 3:30 PM, an interview with The Director of Human Resources (Staff #10) showed that the medical accommodation evaluation process did not include verification of the provoder's signature and confirmed that three forms reviewed were incomplete.

5. Review of the policies titled, "Exposure Control Plan (Covid-19)," Revised 11/05/21, and "Covid-19 Emergency Temporary Standard (ETS) Exemption Policy," no policy number, effective 07/30/21, showed that neither policy contained information regarding the medical exemption evaluation and approval process.


Item #3 Requirements for Vaccine Exempt, Unvaccinated Staff

1. On 03/17/22 at 1:00 PM, an interview with the Infection Preventionist (Staff #2) showed that unvaccinated, exempted staff were required to wear an N95 mask at all times when in the presence of others, and that department managers were responsible for ensuring compliance with the masking requirement.

2. On 03/17/22 at 1:40 PM, observation of a Materials Management Staff (Staff #3) showed that the staff member was wearing a non-N95 type mask in the presence of others.

3. On 03/17/22 at 1:40 PM, an interview with Staff #3 confirmed that Staff #3 was vaccine exempt, and was aware of the requirement to wear an N95 mask when in the presence of others. Staff #3 stated that she did have an N95 mask but that it was back on her desk.

4. On 03/18/22 at 9:00 AM, an interview with the Interim Chief Financial Officer (Staff #4) showed that Staff #4 was aware of the requirement to enforce the specifics of accommodations for his direct reports, but was unaware that Staff #3 was not wearing the required N95 respirator.

5.On 03/17/22 at 1:00 PM, observation of an Intensive Care Unit (ICU) Staff Registered Nurse (RN) (Staff #5), showed that Staff #5 was wearing a KN95 mask.

6. On 03/17/22 at 3:00 PM, an interview with the ICU Nurse Manager (Staff #6) showed that Staff #6 was aware of the requirement to enforce the specifics of accommodations for her direct reports, but Staff #6 was unaware that Staff #5 was not wearing the required N95 respirator.

7. Review of the hospital policy titled, "Exposure Control Plan (Covid-19)," revised 11/05/21, showed that WhidbeyHealth may require that employees who are not fully vaccinated wear an N95 respirator instead of a facemask.

8. Review of the policies titled, "Exposure Control Plan (Covid-19)," Revised 11/05/21, and "Covid-19 Emergency Temporary Standard (ETS) Exemption Policy," no policy number, effective 07/30/21, showed that neither policy contained information specific to accommodation requirements for unvaccinated staff.


Item #4 Tracking of Temporary Vaccine Exemptions

1. Review of 4 forms titled, "Request for Accommodations - Medical Exemption", submitted by staff, showed:

a. Staff #18 requested a temporary accommodation until 11/06/21.
b. Staff #11 requested a temporary accommodation until 12/01/21.
c. Staff #19 requested a temporary accommodation until 03/22/22.
d. Staff #12 requested a temporary accommodation until 08/03/23.

2. Review of the facility vaccine tracking spreadsheet did not show the staff with temporary exemptions.

3. On 03/17/22 at 12:30 PM, an interview with the Manager of Employee Health (Staff #7), showed that Staff #7 could run a report that showed staff with temporary exemptions, but that running the report regularly was not part of Staff #7's current practice.

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