Failure to Document COVID-19 Vaccine Education and Status for Staff
Penalty
Summary
The facility failed to maintain adequate documentation that staff were educated about the risks and benefits of the COVID-19 vaccine, were offered the vaccine, and that their vaccination status was properly recorded. According to the facility's policy revised in August 2023, staff education and re-education regarding the COVID-19 vaccine should be documented in employee files, and staff should have the opportunity to accept or refuse the vaccine at any time. However, interviews revealed that the Infection Preventionist was unsure who was responsible for tracking staff vaccinations, and the Human Resources staff only had documentation for new employees, with no clear process for ongoing or annual vaccine offers or education. Additionally, the facility's vaccination tracking spreadsheet had not been updated since 2023. A review of an employee file showed that documentation of vaccine declination was only present from 2020, with no evidence of annual education or declination forms. Staff confirmed that they had not been offered the vaccine in several years and had not signed annual declination forms. The Infection Preventionist also noted that the position had been vacant prior to their start in February 2025, contributing to the lack of updated records. These findings indicate that the facility did not follow its own policy or regulatory requirements for documenting COVID-19 vaccine education, offers, and status for staff.