Lack of COVID-19 Vaccination Documentation for New Staff
Penalty
Summary
The facility failed to ensure that all staff members were screened, offered the COVID-19 vaccine, and provided with education regarding the benefits, risks, and potential side effects of the vaccine. Specifically, there was no documented evidence of immunization records for two certified nurse aides who were newly hired. The facility's policy, revised in November 2024, mandates that all staff and residents who decline vaccination must sign a written affirmation indicating they were offered the opportunity for COVID-19 vaccination but declined. However, the immunization records for the two certified nurse aides lacked documentation of COVID-19 immunization, education, or declination. During interviews, the Infection Control Preventionist/Assistant Director of Nursing acknowledged that the facility offered immunizations for COVID-19, influenza, and pneumococcal vaccinations to staff and residents. They admitted that the two newly hired certified nurse aides had only received verbal consent or education, with no documentation to support that education was provided or that declinations were recorded. The Director of Nursing was unaware of the lack of documentation for these two staff members, highlighting a gap in the facility's adherence to its own policy and regulatory guidelines.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective Actions for Residents Identified CNA #1 and CNA #2 was offered COVID-19 vaccine. Residents at Risk: - No resident at risk by deficient practice. - No resident at risk by deficient practice. An audit of new hires was conducted to ensure all new hires have either received the COVID-19 vaccine or have a declination signed on file. Systemic Changes: - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - The facility reviewed Policy and Procedure COVID-19; no revision needed. - Education to Assistant Director of Nursing on the Policy and Procedure COVID-19. - All new hires will be offered the COVID vaccination upon start of employment if they have not received. - Audit tool created to ensure declination is received if staff does not have COVID vaccine. Monitoring of Corrective Actions: - The Director of Nursing or Designee will review all new hires to ensure the facility has a declination on file should the staff choose not to be vaccinated. Bi-weekly x 8 weeks, then monthly x 3 months. Any issues noted will be addressed immediately and reported to the administrator. - On a monthly basis, the Director of Nursing will report the findings to the Administrator. - On a monthly basis, the Director of Nursing or Designee will report findings to the QAPI Committee. - QAPI Committee to determine if further action is required. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025