Failure to Document COVID-19 Vaccination Screening and Offer
Penalty
Summary
The facility failed to maintain documentation of screening, education, and offering of the current COVID-19 vaccination for one of five residents reviewed. Specifically, the electronic medical record for a resident with multiple diagnoses, including Alzheimer's disease, chronic kidney disease, and dementia, did not contain any documentation indicating that the resident had been screened or offered the 2024-2025 COVID-19 immunization. When the surveyor requested documentation, none was available for this resident, and the only policy provided by the facility addressed influenza and pneumococcal vaccinations, with no reference to COVID-19 vaccination procedures. During interviews, the Infection Preventionist (IP) stated that residents and staff are offered immunizations annually, and that education and consent are obtained either directly from the resident or through their Power of Attorney. However, the IP was unable to provide a COVID-19 consent or declination form for the resident in question, explaining that the resident had declined the vaccine in the previous year and was therefore not approached again for the current vaccination year. No further documentation was found after checking with the pharmacy.