Failure to Properly Offer and Document COVID-19 Vaccination
Penalty
Summary
The facility failed to properly offer and document the COVID-19 vaccination for one resident who was eligible for the vaccine. The resident's vaccine record indicated a refusal of the COVID-19 vaccine, but the declination form lacked both the resident's and staff member's signatures. The resident had a BIMS score of 15, indicating intact cognition, and had multiple diagnoses including heart failure, chronic kidney disease, diabetes mellitus, seizure disorder, anxiety, depression, and asthma. The resident's medical record and progress notes documented a refusal of the vaccine, but there was no evidence that the resident was provided with education or that a proper consent or declination process was followed as required by facility policy. During an interview, the resident stated she was not offered the COVID-19 vaccine and confirmed she would have accepted it if offered, despite previously declining influenza and pneumococcal vaccines. The DON acknowledged the lack of signatures on the declination form and stated that staff use these forms to determine if a resident was asked about vaccination. Facility policy requires that residents be provided with education about vaccines and that this education be documented in the medical record, but there was no documentation that this occurred for the resident in question.