Lack of Signed COVID-19 Vaccine Consent for Resident with POAHC
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a signed COVID-19 vaccination consent was present in the medical record for a resident with moderate cognitive impairment and an activated Power of Attorney for Healthcare (POAHC). The facility's policy required a signed consent prior to vaccine administration, but only verbal consent was obtained and documented for the COVID-19 vaccine. The registered nurse (RN) contacted the resident's POAHC by phone and received verbal authorization, then mailed a consent form for signature, which was not returned. The RN did not document the verbal conversation in the resident's medical record, and the POAHC later stated that authorization for all vaccines except COVID-19 was given, with the resident themselves authorizing the COVID-19 vaccine at a later date, despite the POAHC being activated for medical decisions. The Director of Nursing (DON) confirmed that the facility typically works off verbal consents and was unaware of the specific communication between the POAHC and the former DON. The resident's medical record contained a consent form indicating verbal consent, but lacked the required signed authorization as per facility policy. The deficiency was identified through interviews with staff and the POAHC, as well as review of the resident's medical record and facility policy.