Failure to Document COVID-19 Immunization for Residents
Penalty
Summary
The facility failed to ensure that each resident was offered the COVID-19 immunization, as observed during the Recertification Survey. This deficiency was identified in five residents who were sampled for immunizations. There was no documentation available regarding the screening, administration, declination, or education on the COVID-19 immunizations for these residents. The facility's policy required that all residents and their representatives be provided with education about the COVID-19 vaccination, and their decision to accept or decline the vaccination should be documented in the COVID Vaccination Care Plan. However, the facility was unable to provide evidence that these steps were followed for the sampled residents. The residents involved had varying levels of cognitive impairments, ranging from moderate to severe, and their Minimum Data Set assessments indicated that their COVID-19 immunization statuses were up to date. Despite this, the facility could not provide documentation to support these claims. Interviews with the Infection Preventionist and the Director of Nursing revealed that the responsibility for monitoring resident immunization statuses had transitioned from a former nurse to the Director of Nursing. This personnel change led to a lapse in maintaining the immunization program, resulting in the deficiency observed during the survey.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 and will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 9TH, 2025 will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the 2024-2025 COVID-19 vaccine. Education on benefits and potential risk was provided. Declination was received will be documented in the COVID Vaccination Care Plan. The MDS assessment for covid 19 immunization was corrected (3/31/25). The MDS Coordinator responsible for coding MDS comprehensive assessment on covid immunization was educated on improperly coding MDS (3/31/25). All Licensed nurses responsible for offering and educating residents the Covid vaccine were educated and re-inserviced on failure to offer, screen educate and document in the COVID Vaccination Care Plan (3/31/25). II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered COVID-19 vaccine upon admission with documentation in EMR related to the screening, administration or declination, and education on the COVID-19 immunizations. An audit was completed by the DNS on the COVID-19 Vaccination to ensure that all current residents in house were offered the COVID-19 Vaccination with signed consent/declination and education on file. Any identified issues will be addressed (3/25/25). III. Systemic Changes: The Policy and Procedure for COVID-19 Vaccination Administration for Residents was reviewed by the DNS and Administrator and found to be in compliance. On 3/31/2025 all licensed nurses received a re-inservice/education on ensuring that all residents are offered the COVID-19 vaccine upon admission. A matrix tracker was created to monitor the COVID-19 Vaccination status of all residents. Newly appointed Infection Control nurse was inserviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Covid vaccine, if appropriate, and vaccine status documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the COVID-19 vaccine upon admission. The DNS will conduct this audit weekly for 3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person responsible: DNS Date: 4/25/25