Failure to Provide and Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to implement its policy regarding COVID-19 immunization education and documentation for all residents. Specifically, there was no evidence that residents or their responsible parties received education about the benefits, risks, or potential side effects of the COVID-19 vaccine. Additionally, there was no documentation indicating whether residents received the vaccine, declined it, or were exempt due to medical contraindications. This deficiency was identified through record reviews and interviews, which revealed that neither education nor offers of vaccination were documented for any of the 74 residents, including those specifically reviewed for immunization status. Record reviews for several residents showed that none had physician orders for COVID-19 vaccination, and immunization audit reports indicated that these residents and their representatives were not offered the vaccine or provided with education since their admission or for extended periods. The facility's documentation did not include any forms or records of declination, education, or consent related to COVID-19 immunization. The Director of Nursing (DON), who also served as the Infection Preventionist, confirmed during interviews that there was no documentation of education or refusal for any resident and that no declination forms were in use or scanned into the electronic system. The Administrator corroborated that no education or documentation had been provided regarding COVID-19 vaccinations for any resident in the past two years, citing lack of interest and refusals from residents or families. The facility's policy required that residents and staff be educated about the vaccine and that documentation reflect the education provided and the vaccination status, but these steps were not followed or recorded for any resident.