Lack of COVID-19 Vaccination Documentation for Resident
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency was identified when a resident with diagnoses including migraines, muscle weakness, chronic pain syndrome, and acute respiratory failure did not have documentation of COVID-19 vaccination or a declination in her medical record. During a record review, it was found that there was no evidence of the resident receiving the COVID-19 vaccine or formally declining it. An interview with the MDS consultant confirmed that neither vaccination nor declination documentation could be located in the system. The facility's policy requires adherence to CMS, CDC, and governmental guidance for COVID-19 prevention and management, but this was not reflected in the resident's records.