BAPTIST RETIREMENT COMMUNITYCOVID-19 PANDEMICESSENTIAL CAREGIVER ACKNOWLEDGEMENT OF RISK UNDERSTANDING and ACKNOWLEDGEMENT OF RISKS. I understand and
acknowledge the following:1.
According to the Centers for Disease Control
(the “CDC”), adults age 65 and older and those with underlying health
conditions (especially if not well controlled) may be particularly susceptible
or at higher risk for illness and death or complications from COVID-19. Such
underlying conditions include, but are not limited to, chronic lung disease,
heart conditions, suppressed immune system, obesity, diabetes, kidney disease,
liver and other gastrointestinal diseases,
cancer and post cancer recovery.2. Persons
in congregate settings (multiple people living together such as at the
Facility) may be at risk of contracting COVID-19 even when all appropriate
interventions and preventative measures are in
place.3.
The CDC has noted that a congregate setting,
with a medically frail and/or older resident population, are at high risk of
being affected by respiratory pathogens like
COVID-19.4.
The CDC has stated that there is evidence that
COVID-19 is spread by asymptomatic and pre-symptomatic infected individuals.
This means that the silent spread of COVID-19 may go undetected in congregate
living situations even with appropriate precautions
and can be transmitted by infected persons who do not exhibit signs or symptoms
of illness.5.
I am requesting access to the premises
of the Facility identified above during a COVID-19
pandemic and acknowledge and accept that such admission is contingent on my
agreement to follow all Facility visitation rules and regulations, including all
required and recommended COVID-19 precautions.
These precautions include, but not limited to, wearing a mask, maintaining
social distancing during my visitation and not visiting common areas of the
community. I further agree that I am solely responsible for the expense, if
any, of such test. 6.
I understand and acknowledge that my own
activities when I am outside of the Facility during this COVID-19 pandemic
could impact the health of Facility residents and staff and that therefore I am
accountable for wearing personal
protective equipment such as a mask, observing social distancing and hand washing
recommendations, when I am outside the Facility so I do not put residents and
staff at potential risk when I enter the Facility as a visitor.7. Despite
adhering to all requested precautions, there is still a potential I could be
exposed to and contract COVID-19 while on Facility premises and that the Facility cannot guarantee a COVID-19
risk-free environment.8. As
a “ESSENTIAL CAREGIVER” visitor, I acknowledge:
- The facility has trained me in the use of PPE and
other infection control measures.
- I will use proper community approved PPE at all times during my scheduled
visit.-
I must
identify myself as well as wear a community provided ID during each visit.-
I must
stay in the resident room, maintain caution, social distance where possible and
will not be near other residents or staff.-
I must
follow the community protocols in making an appointment for the visits as well
as follow all COVID-19 risk mitigation restrictions. Essential caregivers no longer are required to present a negative test result prior to their visit with residents in Nursing areas. Testing is still strongly encouraged to protect all residents and associates.
I HAVE READ, AGREE TO, AND VOLUNTARILY
SIGN THIS VISITOR ACKNOWLEDGEMENT OF RISK EFFECTIVE AS OF THE DATE SET FORTH
BELOW.