HospitalInspections.org

Based on observation, interview, and record review, the facility failed to develop and implement policies and procedures to ensure that all staff are fully vaccinated for COVID-19 resulting in the potential for poor patient outcomes, up to and including death, for all patients served by the facility. Findings include:

On 3/2/2022 at 1300 a review of vaccinations according to the QSO memorandum QSO-22-07-ALL was conducted . A review of the vaccinations was conducted with staff R, the Corporate Manager of Compliance and Staff S, the Strategic Projection Specialist. During the review of Covid vaccination status it was revealed six contractors for the facility were out of compliance for vaccination attestations. The attestations are an agreement between the facility and the contractors to keep vaccination status of the contractor's employees who work in the facility. On 3/2/2022 at 1310, Staff R was queried why the six contractors failed to have attestations. Staff R explained, "We have approached each contractor multiple times to have attestations completed ...Each contractor refuses to comply. In an instance where only two companies in the entire state service the equipment we have no other options...we are being held hostage. If we go outside of the authorized service providers we face having warranties become void for the coverage of the equipment. We as an organization have multiple meetings every week trying to problem solve and look at different approaches to engage the contractors to comply with the mandate. At this time the organization as a whole continues to work on a solution to become compliant. The organization has gone as far as purchasing a computer program for monitoring compliance to ensure we are doing as much as possible to achieve compliance."

Based on observation and interview the facility failed to ensure signage posted in the Emergency Department would not compel individuals to leave the Emergency Department prior to receiving a medical screening exam resulting in the potential for less than optimal outcomes for all patients presenting to the Emergency Department. Findings include:

At the time of entry to the facility on 3/1/2022 at 0930 it was revealed the facility had a sign posted at the entrance of the ED that stated, "PLEASE NOTE: We are experiencing significantly long waits. Care in the ED is prioritized based on severity of condition. For all non-life-threatening concerns, call your primary care office first. On-call is available after hours." On 3/1/2022 at 0940 after entrance to the facility, Staff BB Senior Regulatory Accreditation Specialist was shown the signage posting. Staff BB was queried where the signage was posted elsewhere. Staff BB stated she had never seen the posting and had no idea where the sign originated. Staff BB removed the signage immediately when told that the signage could be considered a deterrent for people seeking care in what the person considers deemed an emergency.

On 3/2/2022 at 0830 at the time of entry to the facility on the second day of survey the sign was posted at the facility's main entrance. Staff BB was alerted to the sign and immediately removed the sign. Staff BB was asked if the sign was issued from a corporate level. Staff BB stated that she had investigated the origination of the sign with no luck. On 3/2/2022 at 1300 during a interview with Staff R, the Corporate Manager of Compliance an inquiry was made where the signage had originated. Staff R stated she was unaware of where the sign had originated and that all facilities were being checked to ensure the sign was not posted within the system. Staff R stated the sign was not approved by any person she had spoke with during her investigation of the origination of the sign.