Failure to Document and Offer COVID-19 Vaccine to Staff
Penalty
Summary
The facility failed to ensure that five sampled employees, including several CNAs, an LVN, and the Director of Rehabilitation, were offered the COVID-19 vaccine as required. Interviews with the Infection Preventionist Nurse (IPN) revealed that while she is responsible for offering and documenting immunizations, there was no documentation showing that these employees were offered the COVID-19 vaccine or that they declined it. The IPN stated that she provides education and re-offers the vaccine, and if declined, employees are supposed to sign a declination form. However, she acknowledged that she did not have documentation of these offers or declinations for the sampled staff. A review of the facility's Coronavirus Vaccine Policy indicated that COVID-19 vaccinations are to be offered to all staff and residents, with documentation maintained for all individuals regarding their vaccination status. The Director of Nursing confirmed that the IPN is expected to document when staff are offered the vaccine, particularly upon hire. The lack of documentation and failure to ensure the vaccine was offered to these employees constituted a deficiency in following the facility's own policy and regulatory requirements.