Failure to Offer, Educate, and Document COVID-19 Vaccination for a Resident
Penalty
Summary
A deficiency occurred when the facility failed to follow its policy regarding COVID-19 vaccination for one resident out of five reviewed for immunizations. The resident reported not recalling being offered or educated about the COVID-19 vaccine. Upon review, the Infection Preventionist was unable to locate documentation of consent, education, or administration of the COVID-19 vaccine for this resident. The Infection Preventionist stated uncertainty about whether the vaccine was offered or administered and acknowledged the absence of required documentation. Further, the Director of Nursing confirmed that the facility's process includes reviewing immunizations upon admission, providing education on the importance and benefits of the COVID-19 vaccine, and obtaining informed consent, all of which should be documented. However, the resident's immunization record lacked any indication that the COVID-19 vaccine was offered, administered, or that education and consent were provided. The facility's policy requires notification, education, and documentation of acceptance or declination of the vaccine, which was not followed in this instance.