Lack of COVID-19 Vaccine Signage in Facility
Penalty
Summary
The facility failed to implement an effective infection control program to prevent the transmission of diseases, specifically regarding the conspicuous posting of COVID-19 vaccine availability. During the Recertification Survey, conducted from January 26 to January 30, 2025, surveyors observed that there were no visible signs throughout the facility informing residents, families, visitors, and staff about the availability of COVID-19 vaccinations. This lack of signage was noted in various locations, including the 1st Floor Lobby, facility elevators, staff areas in the basement, and all resident units. The Director of Nursing, who also serves as the facility's Infection Control Preventionist, confirmed in an interview that the facility offers Influenza, Pneumonia, and COVID-19 vaccines to staff and residents. However, the Director was unaware of why the previously created and posted signs were no longer visible throughout the facility.
Plan Of Correction
Plan of Correction: Approved February 27, 2025 This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Facility will ensure that signage of offering Flu, Pneumonia, RSV and Covid vaccine for Residents and staff members will be posted in the lobby, elevator, time clock and on each unit. 2) How the facility identified other residents: All Residents and staff members can be affected by this deficient practice. All signs were audited and posted to the designated areas and visible to readers. 3) Measures put into place/System changes: Nurse Educator re-in-serviced the Director of Nursing and Infection Control Preventionist of the facility providing Flu, Pneumonia, RSV and Covid vaccine for Residents and staff members and the Precautions Guidelines Notification Policy for Signage Posting for Flu, Pneumonia, RSV and Covid vaccine for Residents and Staff Members. All staff members were re-in-serviced of the facility providing Flu, Pneumonia, RSV and Covid vaccine for Residents and staff members. Precautions Guidelines Notification Policy were reviewed and updated to include Signage Posting for Flu, Pneumonia, RSV and Covid vaccine for Residents and Staff Members. 4) How the corrective actions will be monitored: An Audit tool was developed on monitoring with compliance with Vaccines offering signage for Residents and Staff members on the designated areas. Nursing Supervisor and/or designee will monitor for signs placement daily for 3 months to ensure compliance. Audit tool will be collected by Infection Control Preventionist weekly. Infection Control Preventionist will be responsible for the implementation and monitoring of the plan, ensuring signages were posted, and will oversee the steps stated in all the elements are implemented. ADON/Infection Control Preventionist will submit results of Audit to Administrator/DNS weekly for next two quarters until compliance is achieved. The result of the audits will be presented in the quarterly QAPI meeting.