Failure to Document and Track COVID-19 Vaccination Status for All Staff
Penalty
Summary
The facility failed to provide documented evidence of COVID-19 vaccination screening, education, offering, and current vaccination status for all employees, including on-call and part-time staff, as well as medical doctors and other licensed professionals who enter the facility. During interviews, the Infection Prevention Nurse (IPN) acknowledged not having the COVID-19 vaccination status for these groups and stated that such information is important to prevent staff from being exposed to and acquiring the infection. The Director of Nursing (DON) confirmed that all employees, including the Director of Staff Development, nurses, CNAs, MDs, and NPs, are considered staff and that vaccination status is important to prevent outbreaks. A review of the facility's policy and procedure on staff immunizations indicated that staff includes anyone providing care, treatment, or services for the facility or its residents, including those under contract or other arrangements, and that documentation of vaccination should be maintained. The policy also requires the Infection Preventionist to maintain surveillance data on vaccine coverage and reported rates among residents and staff. The lack of documentation and tracking for all required staff groups led to the deficiency.