Improper COVID-19 Vaccine Administration Interval
Penalty
Summary
A deficiency occurred when a resident with a history of stroke, dementia, and prior COVID-19 infection received two doses of the Pfizer COVID-19 2024-2025 vaccine only nine days apart, rather than the recommended interval. The resident was documented as cognitively intact and required varying levels of assistance for daily activities. The immunization report showed that the first dose was administered on 10/9/24 and the second on 10/18/24, both in the left deltoid, while the resident was in the facility. The registered nurse responsible for vaccine administration stated that her process included obtaining consent, providing the Vaccination Information Sheet, and documenting the vaccination in the electronic medical record (EMR). She was unaware that the resident had already received the vaccine earlier in the month and indicated that she would not have administered the second dose had she seen the prior documentation. The nurse also noted that vaccine administration was communicated during shift reports and only documented in the vaccination section of the EMR, not in progress notes. Facility policy required documentation of immunizations in the medical record, including specific details, but did not specify documentation in progress notes.