Failure to Annually Offer and Document COVID-19 Vaccine to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its own policy and procedures. The policy required that each resident be offered the COVID-19 vaccine unless medically contraindicated or already immunized, and that appropriate documentation be made if the vaccine was not administered due to contraindication, prior vaccination, or refusal. Review of the medical record for one resident revealed that after a documented declination of the COVID-19 vaccine by the resident's responsible party, there was no evidence that the vaccine or informed consent was offered again on an annual basis as required by the facility's policy. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that there was no documentation of an annual offer or consent for the COVID-19 vaccine after the initial declination. The staff acknowledged that the vaccine and consent should have been offered annually and that documentation was lacking. The resident in question had the capacity to make medical decisions, and the failure to offer and document the annual vaccine offering was verified by facility staff during the survey.