Failure to Implement COVID-19 Vaccination Policy and Documentation
Penalty
Summary
The facility failed to implement its COVID-19 vaccine policy for three of five residents reviewed for immunizations. According to the facility's policy, residents and staff are to be educated about the COVID-19 vaccine, offered the vaccine, and have their vaccination status properly documented. For residents aged 65 and older, the policy requires two doses of the 2024-2025 COVID-19 vaccine, while those aged 12-64 require one dose. Review of records revealed that two residents in their 70s and 80s received only one dose of the 2024-2025 vaccine, with no documentation of a second dose being administered or offered, despite signed consent forms. Additionally, there was no documentation of education provided to one of these residents or their representative. Another resident, in their 60s and under 65, had a signed consent form for the COVID-19 vaccine but no documentation of vaccine administration, history, or assessment of eligibility. Interviews with the Infection Preventionist confirmed these findings and clarified that there was no shortage of vaccine supply, as doses could be ordered from the pharmacy as needed. The lack of documentation and follow-through on vaccine administration and education for these residents constitutes a failure to follow the facility's established COVID-19 vaccination policy.