Failure to Provide, Offer, and Document COVID-19 Vaccination per CDC Guidance
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and properly document the administration of COVID-19 vaccinations in accordance with CDC recommendations and its own policies for five residents. The facility's policies require that all residents be offered vaccines unless medically contraindicated, that education be provided prior to vaccination, and that all actions be documented in the medical record. However, record reviews revealed that for several residents, there was either no documentation of education, no record of the vaccine being offered, or incomplete records regarding vaccine administration and consent. For example, one resident's consent form indicated refusal due to already having received a vaccine, but the form was undated and lacked details about which vaccine was received or when. Another resident's record showed receipt of a previous season's vaccine but did not indicate whether the current vaccine was offered or accepted. In two cases, residents or their representatives signed forms indicating acceptance of the current vaccine, but there was no documentation that the vaccine was actually administered. Additionally, for some residents with severe cognitive impairment, there was no evidence that the vaccine was offered to their representatives or that any decision was documented. Interviews with staff revealed confusion regarding who was responsible for coordinating vaccine consents and administration, especially following the abrupt departure of the Infection Preventionist. Staff were unable to locate administration records for residents who had signed consent forms and were unsure if the vaccine had been offered to all eligible residents. The electronic immunization records were often incomplete or blank, further indicating a lack of proper documentation and follow-through on vaccination protocols.