Failure to Offer and Document COVID-19 Vaccination for Resident Under Conservatorship
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to one resident who was under the care of a public conservator, as required by facility policy and CDC recommendations. The resident, who had diagnoses including dementia and schizoaffective disorder, was admitted under conservatorship, with the public conservator's office acting as the responsible party for medical decisions. Upon review of the resident's clinical record, there was no documentation that the COVID-19 vaccine had been offered, nor that the risks and benefits had been explained to the resident or the responsible party. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to contact the conservator's office for consent but did not follow up, resulting in no action being taken. Interviews with facility staff, including the ICN and the Director of Nursing (DON), confirmed that the expectation was for all residents to be offered the COVID-19 vaccine, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's policy also required that educational materials be sent to responsible parties and that general consent be obtained. The lack of documentation and follow-up meant that the resident was not offered the vaccine, and there was no evidence that the required education or consent process occurred.