Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to a resident who was admitted with diagnoses including epilepsy, dysphagia, and depression. The resident's care plan did not identify any contraindications to vaccination, and the quarterly MDS assessment indicated the resident had intact cognition and was independent in personal care and mobility. A review of the clinical record showed that consent forms for vaccination were unsigned, and the resident was not up to date with the COVID-19 vaccine, with the last administration occurring several years prior. The Director of Nursing Services confirmed that it was the responsibility of the LPN or Nurse Supervisor to ensure consent forms were signed within two days of admission, but could not explain why the forms remained unsigned for over six months. Additionally, the facility was unable to provide a COVID-19 vaccination policy as required.