Failure to Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the COVID-19 vaccine for two residents. Resident R6, who was admitted to the facility with diagnoses including hypertension, coronary artery disease, and cancer, had not received an up-to-date COVID-19 booster vaccine. The clinical records did not include documentation that a booster was offered or that education was provided to the resident. The last recorded COVID-19 vaccination for Resident R6 was in 2021, and the Minimum Data Set (MDS) indicated the resident was not up to date with the COVID-19 vaccine. Similarly, Resident R63, admitted with multiple sclerosis, seizures, and gastroesophageal reflux disease, had no documentation in their clinical record indicating that a COVID-19 vaccination was offered or that education was provided. The MDS for Resident R63 also showed that the COVID-19 vaccine was not up to date. Interviews with the Regional Clinical Director-Infection Preventionist confirmed the lack of documentation for both residents, indicating a failure in the facility's processes to ensure proper COVID-19 vaccination documentation and education.
Plan Of Correction
R6 and R63 have been offered covid immunizations. To identify other residents that have the potential to be affected, the Infection Preventionist (IP)/designee reviewed current residents to validate if they have received covid vaccinations. The medical records will be updated accordingly if they received said vaccinations at an outside setting. Those residents who have not received covid vaccinations will be reviewed with the physician for appropriateness to offer. To prevent this from recurring, the RDCS educated the facility IP re: offering vaccinations for residents per policy. To monitor and maintain ongoing compliance, the Infection Preventionist/designee will review 3 residents weekly x4 then monthly x2 to ensure residents are offered covid vaccines and that vaccinations are provided and documented accurately and timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.