Failure to Administer and Document COVID-19 Vaccination After Consent
Penalty
Summary
The facility failed to develop and implement a COVID-19 vaccination policy and did not ensure that eligible residents received the COVID-19 vaccine after consent was obtained. Specifically, three residents with consent for vaccination did not have documentation of their COVID-19 vaccination history, and the vaccine was not administered as required. For one resident with severe cognitive impairment and multiple diagnoses, the resident's representative had provided consent for vaccination, but there was no evidence in the Massachusetts Immunization Information System or facility records that the vaccine was given. The MDS assessment confirmed the resident was not up-to-date with the COVID-19 vaccine. Additionally, for two other residents, the facility did not maintain documentation of their COVID-19 vaccination history and did not administer the most up-to-date vaccine after consent was obtained. Staff interviews revealed that the expected process was to obtain vaccination history upon admission, secure consent, obtain a physician's order, and administer the vaccine. However, the facility had no written COVID-19 vaccination policy, and there was no documentation of efforts to order or provide the vaccine. The survey team was not provided with evidence of a pharmacy request for new vaccines by the end of the survey.