HospitalInspections.org

Based on document review and interview, the facility failed to ensure the staff (10.79%) were fully vaccinated in ninety-seven (97) instances within nineteen (19) departments (Acute Rehabilitation, Intensive Care Unit, Intermediate Care Unit/6 West, Medical Surgical Unit, 2nd floor Psychiatric Unit, 3rd floor Psychiatric Unit, Cardiac Cath Lab, Laboratory, Surgery Admitting Unit, Post Anesthesia Care Unit, Emergency Department, Respiratory Therapy, Oncology Outpatient Unit, Diabetes Center, Sleep Clinic, Patient Registration, Environmental Services, Food Services and Case Management).

Findings include:

1. Review of the facility policy titled, "Coronavirus Vaccination Program", policy/procedure number IC 2.81, indicated all covered personnel are required to have a coronavirus vaccine or must request and obtain an accommodation for an approval medical/religious exemption and comply with testing procedures. Employees who were not fully vaccinated, or otherwise exempted by the deadline may be placed on suspension without pay. If the employee was still not in compliance after suspension, the employee may be subject to corrective action. The Contingency Plan for staff who have not completed the primary vaccination series for COVID 19. To ensure those staff who were not fully vaccinated, or have been granted an exemption or accommodation authorized by law, or who have a temporary delay, adhere to additional precautions. To potentially reduce the risk of COVID 19 transmission the following mitigation steps may be implemented, as applicable - required at least weekly testing for exempted staff and staff who have not completed their primary vaccination series, until the regulatory requirement was met. This policy was effective 03/01/2022.

2. Review of the COVID-19 Vaccine Compliance spreadsheet for H # 2 (Acute Care Hospital) received by A # 1 (Manager Systems/Interim Infection Control Officer) and A # 5 (Employee Health Registered Nurse), indicated the facility was tracking a total of 899 staff members which 802 (89.21%) employees which were either vaccinated and/or had been granted an exemption and 97 (10.79%) employees had not been vaccinated and/or granted an exemption). The non compliant staff members were from the following departments (total 19) and had the following number of personnel (total 97) who were non-compliant (not vaccinated/exempt):
a. Emergency Department - 15
b. Intensive Care Unit - 3
c. Intermediate Care Unit 6 West - 20
d. Medical Surgical Unit 5 West - 19
e. Behavioral Care Unit 3rd floor - 3
f. Behavioral Care Unit 2nd floor - 2
g. Acute Rehabilitation Unit - 13
h. Cardiac Cath Lab - 2
i. Laboratory - 1
j. Case Management - 5
k. Environmental Services - 2
l. Patient Registration - 1
m. Post Anesthesia Care Unit - 2
n. Diabetes Center - 1
o. Oncology Outpatient - 1
p. Surgery Admitting - 2
q. Respiratory Therapy - 1
r. Sleep Clinic - 3
s. Food Service - 1

3. Review of the Infection Control Committee Meeting Minutes dated 04/20/2022, indicated fully vaccinated staff was required by March 15, 2022 and Human Resources and Employee Health were working towards 100% because H # 2 will be cited if not compliant.

4. In interview on 05/20/2022 at approximately 1:00 pm with administrative staff member A # 1 (Manager Systems/Interim Infection Control Officer), confirmed that he/she was acting as the Interim Infection Control Officer. The numbers were accurate and up to date. The situation had been brought up at the Infection Control Committee meetings in April 20, 2022 and again May 18, 2022 (minutes have not been typed up).

5. In interview on 05/20/2022 at approximately 4:15 pm with administrative staff member A # 2 (Chief Nursing Officer), confirmed that the exempt and non-compliant personnel have not been getting tested weekly according to the contingency plan. Personnel only get tested if symptomatic.

6. In interview on 05/20/2022 at approximately 4:30 pm with administrative staff member A # 5 (Employee Health Registered Nurse), confirmed that he/she had no additional personnel at this time that have been vaccinated.

7. In interview on 05/20/2022 at approximately 5:00 pm with administrative staff members A # 1, A # 2, A # 3 (Nursing Quality), A # 4 (Human Resource Director) and A # 5, confirmed that they had no additional documentation (religious/medical exemptions and/or vaccination cards) for personnel that are non-compliant with the vaccination mandate.