Failure to Document COVID-19 Vaccine Education for Residents
Penalty
Summary
The facility failed to provide evidence that education on the risks, benefits, or side effects of the COVID-19 vaccine was given to two residents or their representatives. The facility's policy requires documentation of such education in the resident's medical record, but this was not found for two residents reviewed. Resident 8's representative refused the COVID-19 vaccination, but there was no documentation indicating that they were educated on the vaccine's benefits, risks, or potential side effects. Similarly, Resident 25 received a COVID-19 booster, but there was no evidence that the resident or their representative received the necessary education. During interviews, the facility's Infection Preventionist stated that they provide verbal education and distribute Vaccine Information Statements, but do not use consent or declination forms. The Nursing Home Administrator confirmed that education should have been documented for the residents in question. The deficiency was identified based on a review of facility policy, clinical records, and staff interviews.
Plan Of Correction
1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine and noted on clinical record as refusal, declination documented. R25 last received the COVID-19 booster vaccine on October 20, 2024 and representative was educated on the benefits, risks and potential side effects of the Covid-19 vaccine, no adverse effects related to this practice were observed. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the Covid-19 vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the Covid-19 vaccine and or booster as part of the facility vaccination program. 3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations, including the Covid-19. 4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate Covid-19 vaccines and documentation is completed by the DON and/or IP Nurse. Throughout the uptick of the Covid-19 season, new resident files will be audited to ensure the Covid-19 vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the Covid-19 vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review.