Failure to Document COVID-19 Vaccine Education and Status for Staff
Penalty
Summary
The facility failed to maintain proper documentation regarding COVID-19 vaccination screening, education, offering, and current vaccination status for three out of four sampled staff members, including a registered nurse and two licensed practical nurses. Review of employee files revealed no evidence that these staff members were offered the COVID-19 vaccine or provided with education about its benefits, risks, and potential side effects. Additionally, there was no documentation of their vaccination status or any declination of the vaccine. Interviews with staff confirmed that some had not been educated about or asked regarding their COVID-19 vaccination status, nor had they signed any related forms or provided vaccination cards. The Interim Director of Nurses/Infection Preventionist acknowledged that the facility had not provided or documented COVID-19 vaccine education for all employees and did not have the required documentation for staff immunization status. The Interim Administrator also confirmed the lack of appropriate documentation reflecting that required COVID-19 vaccine education was provided to employees. The facility's policy and CMS guidance require education, offering, and documentation of COVID-19 vaccination for staff, but these steps were not followed or recorded for the sampled staff members.