Failure to Offer and Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine or provided with education on the benefits and risks of the vaccine, as required by facility policy. The policy specified that residents should be given the opportunity to receive immunizations, have their immunization status reviewed upon admission and on an ongoing basis, and receive documented education about the vaccines for which they are eligible. Documentation should include written consent or declination, and administration or referral for vaccination. In this case, the resident was admitted with a history of heart failure, heart disease, and mild cognitive impairment, and was being treated for an upper respiratory infection. Review of the resident's records showed that the most recent COVID-19 booster was received several months prior to admission, and there was no documentation of consent or declination for a new COVID-19 vaccine. The Infection Preventionist confirmed that the resident was not offered a COVID-19 vaccine booster at admission or since, resulting in the resident not being current on COVID-19 vaccination.