Failure to Document COVID-19 Vaccine Education and Offer
Penalty
Summary
The facility failed to provide documentation that five out of six residents reviewed had received education and were offered the COVID-19 immunization, as required by facility policy. Upon review of both paper and electronic medical records, there was missing documentation regarding education and consent or declination of the COVID-19 vaccine for these residents. Interviews with the ADON and DON confirmed that education and the offer of immunization should occur on admission, and that a signed declination form should be present if a resident refuses the vaccine. Despite attempts to locate the required forms, the facility was unable to provide documentation for the affected residents. The facility's admission packet specifies that all residents are to be educated and offered the COVID-19 vaccine, with a signature required to indicate acceptance or declination.