Failure to Document COVID-19 Vaccine Education and Consent for Resident with Activated HCP
Penalty
Summary
The facility failed to provide and document pertinent information regarding COVID-19 vaccination for one resident out of five sampled for immunizations. Specifically, for this resident, there was no indication in the medical record that the resident or the resident's Health Care Proxy (HCP) was provided education about the benefits and potential risks associated with the COVID-19 vaccine. Additionally, the documentation did not show whether the HCP consented to or declined the COVID-19 vaccine for the resident. The resident in question was admitted with diagnoses including Delusional Disorder and a history of cerebrovascular accident, and had an activated HCP to make medical decisions. Review of the Informed Consent for COVID-19 Vaccine form revealed that key acknowledgment boxes regarding receipt of information, opportunity to ask questions, and consent or declination of the vaccine were left blank. During an interview, the Clinical Services Coordinator confirmed that the consent form was incomplete and did not document whether the HCP was informed or had made a decision regarding the vaccine.