Failure to Timely Offer and Document COVID-19 Vaccination to Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was timely offered to three residents, as required by policy and regulatory guidance. For one resident, the medical record showed that the COVID-19 vaccine consent form was left unsigned, undated, and incomplete, with no evidence that the vaccine was offered. For a second resident, there was no documentation in the medical record that the COVID-19 vaccination assessment or consent form was completed, nor any indication that the vaccine was offered. For a third resident, both the physical and electronic medical records lacked any COVID-19 vaccination assessment, consent form, or documentation that the vaccine was offered. These findings were confirmed through interviews with a unit manager, who acknowledged the absence of required documentation and the failure to offer the vaccine as per facility policy. The residents involved had complex medical histories, including conditions such as diabetes, heart failure, kidney disease, stroke, dementia, and other chronic illnesses. The facility's infection control policy referenced adherence to CDC and APIC guidelines but was not followed in these cases.