Failure to Document COVID-19 Vaccination Status, Consent, and Education
Penalty
Summary
The facility failed to ensure proper documentation of COVID-19 vaccination status, consents, and education for four residents, despite having a policy requiring such documentation. Record reviews revealed that the immunization records for these residents contained no data regarding their COVID-19 vaccination status, consent, or education. Interviews with facility leadership and staff indicated a lack of consistent processes for tracking and auditing vaccination status, with leadership changes and a transition from paper to electronic records contributing to the deficiency. Staff reported that while the vaccine was offered and refusals were sometimes obtained verbally, there was no consistent documentation of consent or declination, and signatures were not always collected as required by policy. The residents involved had multiple complex medical diagnoses, including schizophrenia, bipolar disorder, asthma, hypertension, and depression. The facility's own policies required that all residents be offered the COVID-19 vaccine, that education be provided, and that documentation of acceptance, refusal, or exemption be maintained in the medical record. However, the investigation found that for the residents reviewed, there was no documentation of education, consent, or vaccination status, and staff were unclear on the current process for tracking and auditing this information.