Failure to Obtain Guardian Consent for COVID-19 Vaccination
Penalty
Summary
Facility staff failed to ensure that the court-appointed guardian of a resident who was incapable of making decisions was provided with education and the opportunity to consent to or decline a COVID-19 vaccine booster on the resident's behalf. The resident's medical record confirmed the presence of a court-appointed guardian since 2017, yet the immunization record only showed electronic consent forms indicating that education was provided and the resident refused the vaccine. There was no documentation that the guardian was contacted, educated, or given the opportunity to provide or withhold consent for the vaccine. Interviews with facility staff, including the current and former Infection Preventionists (IPs), revealed that the established process required contacting the guardian, providing education, and obtaining consent or declination, either verbally or in writing. The electronic documentation system allowed for specifying whether the resident or guardian provided consent, but in this case, the records only reflected the resident's refusal, not the guardian's involvement. The Director of Nursing acknowledged that the electronic documentation did not reflect the required guardian contact.