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F0887
B

Failure to Administer COVID-19 Vaccine per Consent

Battle Creek, Michigan Survey Completed on 05-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with Alzheimer's Disease and diabetes, who was assessed as having severe cognitive impairment, was admitted to the facility and had their spouse designated as Durable Power of Attorney (DPOA) for Healthcare. The DPOA provided verbal consent for the resident to receive a COVID-19 vaccine, as documented on the COVID-19 Vaccine Consent Form. Despite this consent, the resident did not receive the updated COVID-19 vaccine. Review of the immunization history confirmed that the most recent COVID-19 vaccine was administered several months prior to the consent. During interviews, the Director of Nursing (DON) and Assistant Director of Nursing/Infection Preventionist (ADON/IP) were unable to provide documentation or an explanation for why the vaccine was not administered as consented.

Plan Of Correction

F887 – COVID-19 Immunization Element #1: Resident #33 was assessed by the Director of Nursing and/or designee to ensure no lasting effects related to not receiving Covid-19 immunization. Element #2: The Director of Nursing and/or designee reviewed the last 60 days of resident documentation to ensure residents were offered and provided immunization based on consent. Element #3: The Administrator reviewed the policy on General Immunization and revised and necessary. Licensed Nurses were provided re-education on the vaccine policy and procedure to ensure residents consenting to vaccines receive them timely. Element #4: The Director of Nursing and/or designee will audit new admissions weekly to ensure any resident consenting to a vaccination receives it in a timely manner. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025

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