Failure to Document COVID-19 Vaccine Consent for Resident
Penalty
Summary
The facility failed to offer and administer a COVID-19 immunization booster to a resident, identified as Resident 3, who was reviewed for immunizations. The facility's policy requires that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, with proper documentation of consent or refusal. Resident 3 was admitted to the facility in May 2022, and her immunization history showed she did not receive a COVID booster in October 2023 because her responsible party refused consent. However, the facility could not provide documentation of this refusal. Interviews with Employee 8, a registered nurse and infection control staff, confirmed that Resident 3 did not receive any COVID vaccines since her admission, and there was no documentation of consent refusal in her medical record. Despite attempts to contact Resident 3's responsible party for consent, the facility failed to document these efforts adequately. The deficiency was discussed with the Director of Nursing and the Nursing Home Administrator, highlighting the lack of documentation and failure to offer the vaccine as per the facility's policy.
Plan Of Correction
1. Resident 3 family contacted to see if they receive consent if they want the COVID-19 vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for COVID-19 vaccine for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80 (d)(3)(i)-(vii) COVID-19 Immunization. 4. Infection Control Preventionist (IP) /Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of COVID-19 vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.