HospitalInspections.org

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Based on observation, interviews and document review, the hospital failed to develop and implement policies and procedures for fit testing for N95 particulate respirators in 2 of 15 employees (Staff #16, Staff #5), and 1 of 3 contracted staff members (Staff #7).

Failure to implement policies and procedures for fit testing for N95 particulate respirators puts patients, staff, visitors and the community at risk of illness, disability or death.

Findings included:

1. Review of the hospital policy titled, "Transmission-Based Precautions (Isolation Precautions)," #8740-4012 effective date 06/30/21 showed that respirator protection protects staff from hazardous or infectious aerosols, such as Mycobacterium tuberculosis. These devices have a sub-micron filter capable of excluding particles that are less than 5 microns in diameter. Prior to using a respirator, staff must be fit tested for the appropriate size and fit and be in-serviced on the correct use of the respirator.

2 Review of the employee health files for 3 providers and 15 staff members showed that 1 of 15 staff members were not fit tested for N95 particulate respirators (Staff #16). Documentation showed that 1 of 15 staff members (Staff #5) was unable to successfully be fit tested and were to use PAPR or similar equipment (Powered Air Purifying Respirator).

3. On 02/24/22 at 1:18 PM, the investigator observed that an environmental services employee (Staff #5 ) was wearing an N95 mask.

4. On 02/24/22 at 1:18 PM, during an interview with the investigator, an environmentatl services employee (Staff #5) stated that they had been fitted for the mask they were wearing. When asked by the investigator about the failed fit test documented in her employee health file, the employee stated that they had not been able to be fitted for an N95 mask. They stated that they wore an N95 and have not ever used a PAPR, even when cleaning a room with a COVID positive patient.

5. On 02/24/22 at 1:50 PM, during an interview with the investigator, a Registerd Nurse contract employee (Staff #7) stated that they had been fit tested prior to moving to Washington but that was prior to pregnancy when she was fit tested for a size small mask. Staff #7 stated that a size small mask did not fit them at this time. They stated they were scheduled for fit testing the following Monday.

6. On 02/24/22 at 1:55 PM, during an interview with the investigator, the Chief Nursing Officer (Staff #2) confirmed that there was no documentation of mask fit testing for Staff #7 or Staff #16 and that Staff #5 was not in compliance with their fit testing by not wearing a PAPR. Staff #2 stated that hospital policy and procedure was not followed.

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Based on interview and document review, the hospital failed to develop and implement policies and procedures to approve requests for medical exemption from COVID-19 vaccination for 1 of 1 hospital employees (Staff #10), and 1 of 1 contracted staff (Staff #7).

Failure to develop and implement policies and procedures for medical exemptions, places patients, visitors, staff, and the community at risk for illness, disability, and death.

Findings included:

1. Record review of the hospital policy titled, "Implementing Proclamation 21-14 COVID-19 Vaccination Requirement," #8611-056 effective date 08/23/21, showed that the hospital provides a safe and caring environment including following public health orders issued during the COVID-19 pandemic. All health care workers in a health care setting in Washington State were to be fully vaccinated for COVID-19 by October 19, 2021, subject only to disability and religious exemption. Disability accommodation would require documentation from an appropriate health care or rehabilitation professional authorized to practice in the State of Washington stating the individual has a disability that necessitates an accommodation from the mandatory COVID-19 vaccination and the probable duration of the need for accommodation.

2. Review of the hospital form titled, "Model Request for Accommodations: Medical Exemption from Mandatory COVID-19 Vaccination," showed that:

a) The provider certified that the methods of vaccinating against COVID-19 had been considered, and the following medical contraindication precluded any/all vaccinations for COVID-19. Guidance for medical exemptions for COVID-19 were cited at the "Interim Clinical Considerations for Use of COVID-19 Vaccines Currently Authorized in the United States," and the link to the website was provided. The form included 3 options for the provider to check: 1) Severe allergic reaction after a previous dose or to a component of the vaccine, 2) Immediate allergic reaction of any severity to a previous dose or known allergy to a component of the vaccine, or 3) Other medical circumstances preventing vaccination with any available COVID-19 vaccine. For each of these options, the form directed the provider to be specific and describe in detail.

b) By October 17, 2021, all contract agencies shall have provided proof of vaccination requirements or exemption documentation to the hospital for their workers who work at the facility

3. Review of the employee health file for an accountant (Staff #10) showed that the space on the form for explanation was blank. The request was made on 08/24/21 and was approved on 09/02/21 by the Chief Executive Officer (Staff #1). Accommodation was listed as employee was to wear N95 while in buildings and test once per week.

4. On 02/24/22 at 12:30 PM, during an interview with the investigator, the Chief Executive Officer (Staff #1) confirmed that the medical exemption request did not comply with hospital policy.

5. Review of the attestation form for OMNI Staffing Services, dated 09/30/21, verified that the agency had obtained a copy of or visually observed proof of full vaccination against COVID-19 for every employee subject to the vaccination requirements of the Governor's Order, Employer has followed and intends to continue to follow the requirements that apply to health care settings.

6. Review of the Request for COVID-19 Vaccination exemption for a contract staff employed by OMNI Staffing Services showed that the RN (Staff #7) requested a medical exemption. The employee signed the request and a questionnaire completed by the staff member was attached. There was no documentation from a medical provider regarding the medical exemption or signature of a medical professional The questionnaire was noted as accepted 12/05/21 with a signature and identified as OMNI Staffing.

7. On 02/24/22 at 1:50 PM, a contract RN (Staff #7) stated they had recently moved to Washington and was unaware of Washington rules regarding medical exemption. The staff member stated that they had recently had a baby and didn't want to get the vaccine.

8. On 02/24/22 at 1:55 PM, during an interview with the investigator, the Chief Nursing Officer, (Staff #2) stated that the medical exemptions for Staff #7 and Staff #10 did not meet the requirements of the Governor's Order or the hospital policy.