Failure to Document and Administer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to ensure that one of five sampled residents received or declined an updated or booster dose of the COVID-19 vaccine after being screened for eligibility. The resident, who had diagnoses including type two diabetes mellitus without complications and hypertension, was admitted to the facility and identified as eligible for the COVID-19 vaccine. However, the Immunization Audit Report only documented a status of pending immunization, and the Resident Multi-Vaccine Consent Form lacked a signature indicating consent or declination. There was no documented evidence in the clinical record that the vaccine was administered or declined. Interviews with the Infection Preventionist (IP) confirmed that the resident's record did not contain documentation of previous COVID-19 vaccination and that the vaccine had not been administered. The facility's policy required that residents be offered recommended COVID-19 vaccinations upon admission and as eligible, with documentation of acceptance or declination. Despite these requirements and CDC recommendations, the necessary documentation and administration or declination of the vaccine for this resident were not completed.