Failure to Provide COVID-19 Vaccine Education and Obtain Written Consent
Penalty
Summary
The facility failed to provide education on the risks and benefits of COVID-19 immunization and did not obtain written consent for COVID-19 vaccinations for five residents. Medical record reviews for these residents, who had complex medical histories including hypertension, dementia, cerebrovascular disease, dysphagia, chronic kidney disease, Alzheimer's disease, Parkinson's disease, and end stage renal disease, revealed that COVID-19 vaccination consent forms were either not dated, not signed, or only indicated a verbal declination without specifying whether the decision was made by the resident or a representative. There was also no documentation confirming that education on immunization risks and benefits had been provided. Interviews with facility staff confirmed that the consent forms lacked signatures and did not indicate who provided the consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. Review of the facility's policy indicated that resources and counseling on the importance of COVID-19 vaccination were to be offered, but this was not reflected in the documentation for the affected residents.