Failure to Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to offer a COVID-19 immunization to three residents, which was identified during a survey. Resident #41, who was admitted with a urinary tract infection and had intact cognitive functioning, had previously received COVID-19 vaccines but was not offered an additional vaccine as per the facility's records. Similarly, Resident #9, admitted with hypothyroidism and type 2 diabetes, and Resident #55, admitted with severe malnutrition and diabetes, had received previous COVID-19 vaccinations but were not offered further doses according to the facility's documentation. The Director of Nursing (DON) stated that COVID-19 vaccines are offered based on residents' preferences and vaccination history, and that acceptance, refusal, and education are documented in the electronic medical record (EMR) or hard chart. However, upon review, there was no documentation indicating that these residents were offered additional vaccines. Furthermore, the DON was unsure if education was provided after vaccine refusals, as required by the facility's policy. The facility's policy mandates documenting vaccination status upon admission and offering vaccines according to the manufacturer's schedule, but this was not adhered to for the residents in question.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #9, #14 and #55 were educated by the licensed nurse regarding the NJ Ex Order 26.461 and consents and have been offered and administered as ordered. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit on current residents to validate that the COVID-19 vaccinations were offered. If any eligible resident did not receive the COVID-19 vaccination, the physician has been notified, orders placed and consents obtained. 3. Systemic Changes to Prevent Future Occurrences: Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the policy for the COVID-19 vaccination. 4. Monitoring of Corrective Action: The Director of Nursing/designee will conduct weekly audits x4, then monthly x2 on new admissions to validate that the COVID-19 vaccinations were offered. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.