Even healthcare workers who voluntarily are fully vaccinated against COVID-19 warn of the unintended consequences of a federal vaccine mandate, particularly to long-term care and rural facilities already hit hard by the pandemic.1

In comments submitted to the Centers for Medicare & Medicaid Services (CMS), an unidentified infection preventionist (IP) at a long-term care facility in South Dakota said the mandate could compromise resident care and halt new admissions because of inadequate staffing.

“I’m vaccinated — I’m an infection control nurse,” the IP said. “I believe that the vaccine is helpful, but I don’t think it is right to force the vaccine on someone who doesn’t want it. Our facility has 100% of our residents fully vaccinated. We have 79 staff who are fully vaccinated and 15 staff who aren’t vaccinated.”

That’s an 84% immunization rate, but the facility will be in trouble if those unvaccinated workers quit or have to be fired.

“My facility has the potential to lose 15 staff unless they qualify for a waiver,” the IP said. “South Dakota has a serious shortage of licensed nursing staff and well as certified nursing assistants to care for our elders. This shortage isn’t new due to COVID. We struggle daily to find enough staff to work. We have had to reach out to very expensive staffing agencies to find staff. My facility is going to have to shut down a wing, move residents from one room (their home) to another room. How is that good for their emotional health? Give us some other testing options to keep our unvaccinated staff.”

Many other commenters made a similar request, some citing the weekly COVID-19 testing option that is allowed to non-healthcare businesses with more than 100 employed under a separate federal mandate.

Citing the existing nursing shortage, a nurse practitioner in rural Kansas asked that unvaccinated workers be allowed to wear masks and be tested weekly for COVID-19.

“In [my] facility there are approximately 40 people unvaccinated, and 24 of them provide direct patient care,” the nurse practitioner said. “With the enforcement of the CMS regulation, there is a potential of losing one-third of our workforce.

An unidentified healthcare worker at a small rural hospital in Idaho said they also risk losing too many employees if the mandate goes into effect.

“At last count, 92 out of 198 employees are unvaccinated (46%), including eight department managers,” the commenter told CMS. “Losing a key manager or a just a few key staff can shut down some departments. We currently have four departments with more than 70% unvaccinated staff. A hospital cannot function without key departments, such as laboratory, nursing, and radiology.”

The commenter proposed a novel solution, a “hardship exception” for rural providers that immediately would forbid the hiring of new employees who are not vaccinated. “[This would] allow us keep the unvaccinated staff we already have with appropriate precautionary measures for these people going forward (i.e., testing, social distancing, etc.).”

An unidentified healthcare professional in Oklahoma took issue with the CMS’s contention that “few” staff actually have been fired in state and local mandates.

“In a rural setting, even one or two nurses are too many,” the healthcare worker said. “I do agree that these vaccines save lives. I am fully vaccinated, and advocate for vaccination of all. I just don’t agree with the manner in which the mandate occurred.”


  1. 86 Fed Reg 61555 (Nov. 5, 2021).