Failure to Obtain Consent and Provide Education Prior to COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering the COVID-19 vaccine. Clinical record reviews for three residents revealed that, despite receiving the COVID-19 vaccine, their charts lacked documentation of signed consent forms and evidence that education about the vaccine had been provided. These residents had varying cognitive abilities and medical conditions, including arthritis, non-Alzheimer's dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. The facility's policy required that consent be obtained from both the resident and physician, and that education about the vaccine, including benefits and potential side effects, be documented in the resident's permanent medical record. Interviews with facility leadership confirmed the absence of required documentation. The DON acknowledged that the immunization process needed improvement and admitted that while consents were sometimes electronically signed, there was no documentation of education being provided, nor was there a second witness for verbal consents. The Administrator expressed a preference for actual signatures and two witnesses for verbal consents, which was not consistently practiced. These findings indicate that the facility did not follow its own policy regarding COVID-19 vaccination consent and education.