Failure to Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that residents were educated, offered, and received the COVID-19 vaccine if they consented. This deficiency was identified for five residents who were reviewed for immunizations. Specifically, Resident 4 had not been offered an updated COVID-19 vaccine or provided education regarding its risks and benefits since her last vaccine in November 2022. Resident 16, who was admitted in 2022, also lacked documentation of being offered an updated vaccine or receiving education. Similarly, Residents 21 and 53, who last received vaccines in February 2023, were not documented as having been offered updated vaccines or educated on them. Resident 85, admitted in August 2024, had no documented COVID-19 vaccination history, offer, or education. The facility also failed to screen, educate, and offer the COVID-19 vaccine to an employee reviewed, identified as Employee 12, a registered nurse hired in September 2024. There was no documented evidence that the facility screened her for vaccine eligibility, offered the vaccine, or provided education about its risks and benefits. This oversight was confirmed during an interview with the infection control preventionist. The facility's policies for both residents and staff indicated that they would be educated about and offered the COVID-19 vaccine in accordance with CDC and FDA guidelines. However, the review revealed a lack of adherence to these policies, as evidenced by the absence of documentation for the residents and the employee involved. The deficiency was previously cited in January 2024, indicating a recurring issue with the facility's compliance with COVID-19 immunization requirements.
Plan Of Correction
The facility offered Covid vaccinations to residents 4, 16, 21, 53, 85, and to staff member 12. The facility will screen employees and current residents for Covid vaccine eligibility and offer the vaccine or educate on the risks and benefits. The facility's infection preventionist will receive education on the facility's "Covid 19 Vaccine" policy. The DON or designee will audit new hires and newly admitted residents to ensure a Covid vaccine is offered to eligible persons and provide them or their responsible party with education regarding its risks and benefits. The results of the audits will be reviewed at the facility's QAPI meeting for recommendations.