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F0552
D

Failure to Obtain Informed Consent for COVID-19 Vaccine Administration

Pomona, California Survey Completed on 06-27-2025

Penalty

Fine: $64,875
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to obtain informed consent from a resident prior to administering the COVID-19 vaccine. The resident, who had diagnoses including encephalopathy and right-sided hemiplegia following a cerebral infarction, was admitted with documented capacity to understand and make decisions. Despite this, the Infection Prevention Nurse contacted the resident's family member for consent, citing the resident's Spanish-speaking and non-verbal status, rather than obtaining consent directly from the resident. The family member later stated they were never contacted for consent. The resident reported not giving consent for the vaccine and was not informed that the injection was a COVID-19 vaccine, instead being told it would help their right arm move better. Facility policy required that residents or their representatives be given the opportunity to accept or refuse the vaccine. The Assistant Director of Nursing confirmed that, given the resident's capacity, consent should have been obtained directly from the resident.

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