Failure to Document COVID-19 Vaccine Education and Status
Penalty
Summary
The facility failed to implement its policies and procedures regarding COVID-19 immunizations for one of five residents whose records were reviewed for immunization compliance. Specifically, the medical record for a resident admitted in 2024 did not contain documentation that the resident or their representative received education about the benefits and potential side effects of the COVID-19 vaccine. Additionally, there was no record indicating whether the resident received the COVID-19 vaccine, declined it, or had a medical contraindication. The Director of Nursing confirmed that while COVID-19 vaccines were available and the resident had been offered the vaccine in the previous year, there was no documentation of education, consent, or declination in the resident's file for 2024. This lack of documentation was identified through interviews and record review, and had the potential to affect all residents requiring immunization education and consent.