Failure to Implement and Document COVID-19 Vaccination and Education
Penalty
Summary
The facility failed to develop and implement policies and procedures to ensure the availability and proper administration of the COVID-19 vaccine to all staff and residents. There was no documentation that the COVID-19 vaccine was offered, received, or declined, nor was there evidence that education regarding the risks, benefits, and potential side effects of the vaccine was provided to residents or their representatives. A review of the Infection Prevention and Control (IPC) Program policy revealed no specific guidance or materials related to COVID-19 vaccination, education, or outbreak management. Additionally, the Infection Control Book lacked any educational materials, immunization records, or guidelines for COVID-19 management, monitoring, or prevention. For all new admissions within the last 30 days, there was no documentation in the Electronic Medical Records indicating that the COVID-19 immunization was addressed or that education was provided. Interviews with the Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON) revealed further gaps in the facility's infection control practices. The ICPN, newly hired and inexperienced in the role, confirmed she had not developed or implemented an Infection Control Program and was unaware of any previous COVID-19 outbreaks or related policies. She also stated that the facility had not had an ICPN since the previous one left, and that all infection control records and monitoring data were missing, possibly taken or destroyed by a former interim corporate staff member. The DON acknowledged awareness of the missing documentation and the lack of an active infection control program, confirming that the ICPN was expected to rebuild the program from scratch.