Failure to Educate, Offer, and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to provide education, offer, and document COVID-19 vaccination status in accordance with CDC guidance for one resident reviewed for immunizations. The resident, who had a history of chronic pain syndrome, hypertension, and type 2 diabetes mellitus, was admitted to the facility with a prior history of receiving multiple COVID-19 vaccinations before admission. Upon review of the clinical record, there was no documentation of education or a signed consent/declination form for the COVID-19 vaccination as required by facility policy. Interviews with the DON revealed that the facility had not conducted a vaccine clinic since the change in ownership, and the process for administering vaccines between clinics was unclear. The DON was unable to locate documentation or consents for the resident's COVID-19 vaccinations, despite the facility's policy requiring that information and consent forms be provided and retained in the medical record upon admission. The lack of documentation and unclear processes led to the deficiency identified during the survey.