HospitalInspections.org

Based on interview and record review, the facility failed to develop and implement policy/procedure for additional precautions for all non-immunized COVID-19 health care exempt staff that included 4 out of 4 Staff (R, S, T, and U) that were not fully vaccinated for COVID-19 infection, resulting in the potential for the transmission and spread of COVID-19 infections for all 169 patients being served by the facility. Findings include:

On 3/16/2022 at 1020 a review of COVID-19 vaccination exemptions records for Staff R, S, T, and U revealed the following:

Staff R was a Registered Nurse who was granted her request for Religious exemption.

Staff S was a Certified Nurse Anesthetist who was granted her request for Religious Exemption.

Staff T was a Occupational Therapist Specialist who was granted her request for Medical Exemption.

Staff U was a Patient Care Assistant who was granted her request for Medical Exemption.

On 3/17/2022 at 1600, Staff P was asked if unvaccinated staff were required to use a NIOSH (N-95) mask or undergo weekly COVID-19 testing. She replied, we have N-95 available for all staff. She said COVID testing was not required.


Review of the facility's "CMS Mandatory COVID-19 Vaccination" policy effective date 12/3/2021 documented the following:

"...V. Procedures:
I. Requirements Upon Receiving an Exemption: If an exemption is granted, the individual
receiving the exemption will be required to comply with all infection prevention requirements of the facility including always wearing a procedural mask while in the facility unless wearing a N95 respirator per COVID respirator guidelines. Mask can only be taken off when the individual is by themselves (including but not limited to restroom, eating in secluded break area, desk or cubicle, etc.)."