CEOC: Masking guidelines reminder and universal eye protection policy


TO: Ballad Health All

FROM: Ballad Health Corporate Emergency Operations Center

DATE: Monday, July 25, 2022

TITLE: Masking guidelines reminder and universal eye protection policy

ACTION: Please cascade and share with team members.

COVID-19 inpatient cases: 129

COVID-19 patients in ICU: 20

COVID-19 patients on ventilators: 7

Pediatric inpatients with COVID-19: 4

The memo will review the following items:

  • Reminder of current masking guidelines
  • Implementation of universal eye protection in all clinical roles
  • Virtual meetings continue to be encouraged

Click here to view this as a PDF file.

With the summer rise in COVID-19 transmission in our region and in our hospitals, it is important for all team members to follow our Ballad Health masking guidelines, which were implemented in early April and remain in effect.

While COVID-19 admissions are lower than the critical highs we experienced during last winter’s surge, the current BA.5 variant is a concern. The positivity rate for the region has increased to 25%, up from our lowest of 3% just a few months ago. As of Monday, July 25, there were 129 COVID-19 inpatients – a rise from the low of 24 inpatients in late spring – and approximately 140 team members who have COVID-19 right now.

As a reminder, please be diligent about following our masking protocols to protect our patients, visitors and team members.

Team member masking guidelines

  • Masking is still required in all patient care areas.
  • Masks are not required for vaccinated team members in nonpatient-care areas. During times of transmission in a department or area, the leadership of the department and/or infection prevention may institute universal masking to contain an outbreak.
  • Unvaccinated team members in nonpatient-care areas are still required to wear a mask in order to comply with OSHA (Occupational Safety and Health Administration) and CMS (Centers for Medicare & Medicaid Services) guidelines.
    • Unvaccinated team members may remove their mask only when eating and drinking alone.
  • Masks are still required for all team members in public areas where patients may be present, such as waiting rooms, public hallways and lobbies.
  • Facial hair must not prohibit a proper mask or N-95 fit. (See illustration at the bottom of this memo). Masks must provide a close fit and cover the nose and mouth appropriately.
  • Blue badge buddies may be worn to show vaccination status for team members and credentialed medical staff providers – but they are NOT required. All students who are vaccinated may display an orange badge buddy to denote vaccination status. Managers will be required to know the vaccination status of their team members. Those who would like an optional blue badge buddy, demonstrating fully vaccinated status, should contact human resources.
    • Any team member observed by leadership outside patient-care areas without a mask on and without a blue badge buddy will be subject to inquiry into their vaccine status.
    • Unvaccinated team members discovered outside a patient-care area without their mask on, or any team members (regardless of vaccination status) discovered without a mask while in a patient-care area, will receive a mandatory written warning on the first offense. A second offense will result in a mandatory termination of employment.
    • Any unvaccinated team member who is discovered by state regulators or a surveyor from OSHA or CMS without a mask on, resulting in a citation and/or a fine, will be subject to mandatory termination.
  • “Fully vaccinated” is defined as having received two doses of the Pfizer or Moderna vaccines or one dose of the Johnson & Johnson vaccine – but a booster is not required to be considered fully vaccinated. We do, however, encourage receiving a booster, as it has been proven to make a difference in protection against COVID-19.
  • IMPORTANT NOTE: For contact tracing purposes, the Centers for Disease Control and Prevention (CDC) now uses an updated criteria of “up to date” regarding COVID-19 vaccinations, which is defined as having received primary dose(s) PLUS all eligible boosters. Thus, team members who are fully vaccinated (but not “up to date”) who unmask and have a high-risk COVID-19 exposure must still follow enhanced protocols, as instructed by infection prevention.

Universal eye protection is again required for team members in all clinical roles.

To help protect our workforce from illness, the universal eye protection policy is designed to comply with regulatory requirements so that we can accomplish our mission to honor those we serve by delivering the best possible care.

  • All team members in clinical areas must wear the appropriate PPE, including eye protection, during this time of high transmission.
  • Eye protection in any clinical encounter in any environment is required, as it is critical to reducing spread and infection. If you’re not sure about what is required, speak with your supervisor, who can consult with CEOC if additional clarification is needed.
  • These requirements are also in place for suspected monkeypox patients. Please contact infection prevention with any questions.

Meetings and meals

  • As a reminder, avoid overly congregated areas for mealtime.
  • When possible, internal meetings are encouraged to be conducted in a virtual format or to take place by phone.
  • In-person meetings in clinical areas should only take place when necessary and all participants must remain masked, regardless of vaccination status.


Have a question about vaccines, treatments, the BA.5 variant or other COVID-related topics? Contact the Ballad Health Corporate Emergency Operations Center at