Failure to Offer and Educate Staff on COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the most recent COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects associated with the vaccine. This deficiency was identified during a recertification survey conducted from February 10 to February 14, 2025, where it was found that there was no documented evidence that COVID-19 vaccination was offered or that education was provided to ten staff members, including dietary aides, housekeeping staff, certified nurse aides, licensed practical nurses, registered nurses, social workers, dining supervisors, and cooks. The facility's policy, dated November 30, 2024, stated that consenting personnel would be offered the opportunity to receive the COVID-19 vaccine, and signage would be posted throughout the facility to remind personnel and residents of this offer. However, during the survey, no such signage was observed, and the facility could not provide documentation of vaccine offers or education. Interviews conducted during the survey revealed further issues. A licensed practical nurse stated they were not offered the COVID-19 vaccine and had not heard about it, although they would have consented if it had been offered. The Assistant Director of Nursing admitted to not offering the COVID-19 vaccines due to perceived lack of interest among staff, despite acknowledging the importance of staff education on vaccines. The Director of Nursing also admitted to not closely tracking vaccine status for staff and residents and was unaware of the missing signage. These inactions and lack of documentation contributed to the facility's failure to comply with the requirement to offer and educate staff about the COVID-19 vaccine.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F887 Ss=E The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Employee health nurse/ ADON is offering most recent covid 19 vaccinations with education pamphlet regarding benefits, risks and potential side effects associated with vaccine to all eligible staff members. Consent / declination forms and education are logged by Employee Health nurse/ ADON. Dietary aide #15, housekeeping #16, CNA #17, #18, #20, LPN #19, RN #21, Social work #22, Dining supervisor #23 and cook #24 have been provided education pamphlet on covid vaccine and consent/ declination logged week completed 2/25/25. All STAFF have the potential to be affected by this practice - Audit for all staff employed by the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Management of covid 19 was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The Director of nursing will educate the assistant director of nursing/ employee health nurse on covid vaccines, providing education/ information pamphlet and proof of consent or declination. - The Assistant director of nursing/employee health nurse will ensure staff who were offered the covid vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/ infection preventionist/ Designee will perform an Audit for all staff employed in the facility who are eligible for covid vaccine and are being provided with education/ information pamphlet, consent and declinations are being obtained. Eligible staff will be audited weekly for 3 months. Audit for new hires will be done weekly x 3 months. Any discrepancies will be reported to Administrator and immediately corrected, staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.