Failure to Document COVID-19 Vaccine Education for Resident's Representative
Penalty
Summary
The facility failed to ensure that a resident's medical records included documentation that the resident's representative was provided education regarding the risks and benefits of receiving a COVID-19 immunization. This deficiency was identified for one of five residents reviewed for immunization concerns. Specifically, Resident 46, who had a severe cognitive impairment as indicated by a BIMS score of three, signed a consent form for the COVID-19 vaccine. However, the facility did not provide evidence that the resident's responsible party was educated about the vaccine's risks and benefits, which was necessary given the resident's incapacity to make informed medical decisions. The clinical record review revealed that Resident 46 had a diagnosis of dementia and was alert with confusion. Despite this, the resident signed the COVID-19 vaccine consent form, and the vaccine was administered. An interview with the facility's infection preventionist confirmed the lack of documentation regarding the education of the resident's responsible party. The Nursing Home Administrator and Director of Nursing were informed of these concerns, which were previously cited as a deficiency in February 2024.
Plan Of Correction
1. Facility cannot retroactively provide the COVID vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of COVID vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the COVID vaccine informed consent prior to vaccination. 4. DON/designee will conduct random audits of COVID vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.