Failure to Document COVID-19 Vaccine Education, Consent, and Administration
Penalty
Summary
The facility failed to properly document education regarding the benefits and offering of COVID-19 immunizations, as well as the acceptance or declination of the vaccine, for three of five sampled residents. For one resident, the COVID-19 vaccine declination was signed by the resident during the survey, despite the resident having a guardian responsible for making medical decisions. Another resident's record showed a refusal of the vaccine, but the documentation also included a completed acceptance consent, indicating conflicting information. For a third resident, the record showed a completed acceptance for the COVID-19 vaccine, but there was no documentation that the vaccine had actually been administered. During interviews, the Infection Control Preventionist acknowledged the missing documentation and the DON confirmed that immunizations should be provided according to acceptance or declination. The facility's policy requires documentation of education and declination in the clinical record, but this was not consistently followed for the residents reviewed.