Deficiency in COVID-19 Vaccination Documentation for Staff
Penalty
Summary
The facility failed to maintain infection control prevention practices, specifically regarding COVID-19 vaccinations for staff. During a recertification survey, it was found that the facility did not provide documentation of screening, administration, or declination of the COVID-19 vaccine for two staff members, a Certified Nurse Aide and a Laundry Aide. The facility's COVID-19 policy required that all employees and contracted staff be screened and educated about the vaccine, with documentation maintained to reflect this process. However, the facility was unable to provide such documentation for the two staff members in question. Interviews conducted during the survey revealed that the Licensed Practical Nurse responsible for collecting employee immunization data did not have completed forms for the two staff members, indicating a lack of awareness that the COVID-19 vaccine needed to be offered to staff. The Director of Nursing stated that the responsibility for ensuring forms were signed was delegated to the Licensed Practical Nurse, but they were unsure why the documentation was not completed. This oversight led to a deficiency in the facility's infection control practices as per the regulatory requirements.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 Staff #15 and #16 were both offered and declined COVID vaccinations for the year. Consent form was signed on (MONTH) 12, 2025. Staff #17 has been educated on the importance of completion of vaccination forms in its entirety. That Covid vaccinations are available in the facility throughout the year. A full house audit of all staff vaccination status will be conducted by DON/designee. All staff will be offered the Covid vaccines with education and eligibility information. Education provided to Staff #17 all staff can accept or decline all vaccinations throughout the year. Covid vaccinations are available at any time in the facility. Upon request. Covid vaccinations are offered at time of hire and, throughout the year. All vaccinations are available at any time. House wide audit of vaccinations records will be completed by ADON/designee monthly until 100% compliance is attained for 3 consecutive months. Any abnormal findings will be reported to the DON. These findings will be corrected immediately with education provided. The DON/ADON will review audits for compliance. Any negative findings will result in immediate education. The audit results will be reported to QAPI monthly meeting. The frequency of ongoing audits will be determined by the QAPI committee based on audit results. The person responsible for the corrective action is the Director of Nursing/designee. Date of Compliance is 4/18/25.