Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for two of five residents reviewed for immunizations. Specifically, the facility did not offer the COVID-19 vaccine to two residents, as required by both CDC guidelines and the facility's own policy. Both residents had medical histories that placed them at risk, including conditions such as atrial fibrillation, lymphedema, hypertension, chronic osteomyelitis, diabetes, and cirrhosis. Despite these risk factors, there was no documentation in their electronic medical records indicating that the COVID-19 vaccine was offered or administered, nor was there documentation of vaccine refusal. Interviews with the residents confirmed that they had not been offered any vaccinations during their stay at the facility. The DON stated that it was the responsibility of the admitting nurse to offer and document vaccinations, and that refusals or administrations should be recorded in the EMR. However, the facility was unable to provide documentation to support that the vaccine was offered or refused for these residents, indicating a failure to follow established procedures for COVID-19 immunization assessment, education, and documentation.