Failure to Document and Offer COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccination was offered and/or administered to two of five sampled residents in accordance with its policy and procedures. For one resident, the admission record showed they were admitted and readmitted with diagnoses including spinal stenosis, muscle spasm, and GERD. The Minimum Data Set (MDS) indicated the resident was cognitively intact and required assistance with activities of daily living. Upon review of the electronic chart and interview with the Infection Prevention (IP) Nurse, it was found that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident at the time of admission, as required by facility policy. Similarly, another resident was admitted with diagnoses of anemia, generalized weakness, and diabetes mellitus, and was also found to be cognitively intact and moderately dependent on staff for activities of daily living. Record review and interview with the IP Nurse revealed that there was no documented evidence of a consent or declination form for the COVID-19 vaccine for this resident either. The facility's policy, reviewed on 12/18/2020, required that residents be screened for vaccination status and that appropriate documentation be obtained, but this was not followed for the two residents identified.