Deficiencies in COVID-19 Vaccine Offer and Documentation
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 vaccine and provided with education regarding its benefits and risks. Specifically, for three residents reviewed for immunization concerns, there were deficiencies in documentation and education. Resident 2 had a consent form signed for the 2024/2025 COVID-19 vaccine, but there was no evidence of the vaccine being administered. Resident 7's record showed a refusal of the vaccine in 2021, but there was no documentation of any subsequent offer or education about the 2024/2025 vaccine. Resident 10's record lacked any evidence of receiving or refusing the vaccine, as well as any education provided about it. The facility's policy required that residents and their representatives receive education about the COVID-19 vaccine and have the opportunity to accept or refuse it. However, the survey found that the facility did not adhere to these policies for the residents reviewed. The medical records did not include necessary documentation of education provided or the vaccine's administration or refusal, which is a requirement under the facility's policy and federal regulations. Additionally, the facility failed to maintain proper documentation of staff COVID-19 vaccination status as required. Specifically, there was no information provided regarding the vaccination status of Employee 3, a nurse aide, despite requests from the surveyor. This lack of documentation is a violation of the requirement to maintain records of staff vaccination status and related information as indicated by the Centers for Disease Control and Prevention's National Healthcare Safety Network.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 2, 7, and 10 were provided with education on the benefits and risks associated to the covid vaccine and offered vaccine if desired. The clinical record has been updated to reflect the administration of the COVID vaccine as indicated for residents 2, 7, and 10. Employee 3 was provided education on the benefits and risks associated with the covid vaccination and where she can get the vaccination if desired. 2. All residents' covid vaccine statuses for the 2024-2025 vaccine will be reviewed and vaccine offered with education on risks and benefits. All current employee files reviewed for vaccine education acknowledgement. 3. Covid vaccine review with new residents incorporated into admission process including education on risks and benefits. Covid vaccine education given to new staff upon hire with acknowledgement form. 4. DON or designee will complete audits for new resident covid vaccination education and offer and new hires for covid vaccine education weekly x4 then monthly x2 with results reported to QAPI.