Failure to Document COVID-19 Vaccine Refusal and Education
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for two residents, identified as R101 and R133. Resident R101, who was admitted to the facility in 2019, had a Minimum Data Set (MDS) indicating they were not up to date with the COVID-19 vaccination. A review of their clinical record revealed that the COVID-19 vaccination was refused, but there was no documentation of a refusal consent form or evidence that education regarding the vaccine was provided to the resident. Similarly, Resident R133, admitted in 2020, also had an MDS indicating they were not up to date with the COVID-19 vaccination. Their clinical record showed a refusal of the COVID-19 vaccination, yet it lacked documentation of a refusal consent form and proof that education was provided. An interview with the Infection Preventionist confirmed the facility's failure to maintain accurate and timely documentation for these residents.
Plan Of Correction
1. Signed declination forms for Covid-19 vaccination were obtained for R133 and R101. 2. Infection preventionist will conduct an audit of admissions for the last 30 days to ensure consent or declination was signed for Covid-19 vaccination. 3. Director of nursing or designee will in-service licensed staff on offering Covid-19 vaccines and placing completed consent/declination forms in permanent medical record. 4. Director of nursing or designee will audit 5 residents weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure signed consent/declination forms are present in the medical record. Audit findings will be shared with QAPI committee.