Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its policy and CDC guidance. Medical record review showed that the resident, who had diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease, was admitted to the facility after having received a COVID-19 booster prior to admission. Despite being severely cognitively impaired and requiring staff assistance with activities of daily living, there was no documentation in the resident's medical record from the time of admission through the review period indicating that the COVID-19 vaccine was offered, declined, or administered. Additionally, there was no consent or declination form present in the chart, and the DON confirmed the absence of such documentation.