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F0578
D

COVID-19 Vaccine Administered Without Consent Due to Resident Misidentification

Greenhurst, New York Survey Completed on 08-15-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A resident with diagnoses including dementia, depression, and hypertension, who was assessed as cognitively intact, was administered the COVID-19 vaccine despite having signed a declination form indicating refusal of the vaccine. Facility policy required that consent or declination for the COVID-19 vaccination be obtained and documented within seven days of admission, and that residents or their responsible parties have the right to refuse any vaccination at any time, with all education and refusals documented in the medical record. The resident's signed declination was present in the record, and the COVID-19 vaccine was nonetheless administered. The incident occurred when an LPN failed to verify the resident's identity by not checking the wristband prior to administering the vaccine, as required by the facility's medication administration policy. Documentation in the medical record confirmed the administration of the vaccine and a subsequent medication error report noted the failure to follow resident rights and proper identification procedures. Interviews with facility staff, including the LPN, the infection preventionist RN, and the Director of Nursing, confirmed that the vaccine was given in error and that this action violated the resident's right to refuse treatment.

An unhandled error has occurred. Reload 🗙