Failure to Determine and Document Resident COVID-19 Vaccination Status
Penalty
Summary
The facility failed to determine and document the COVID-19 vaccination status of a resident who was admitted and assessed as cognitively intact. Upon review of the resident's electronic health record, there was no signed informed consent, record of administration, or documentation of refusal for the COVID-19 vaccine. Additionally, there was no evidence in the medical record of any past COVID-19 vaccinations administered to the resident. The resident reported that he typically kept his immunizations up to date and had received prior COVID-19 vaccines, but stated he had not been offered the vaccine since admission and was unsure if he was up to date. Interviews with facility staff, including the DON and the Corporate Nurse Consultant, revealed that neither could locate documentation regarding the resident's COVID-19 vaccine status in any records. The DON, who also served as the Infection Preventionist, was new to the facility and unable to confirm if the resident had received or been offered the vaccine. The Corporate Nurse Consultant acknowledged there was no reason for the lack of documentation and recognized areas for improvement in the immunization process, but no new process had been initiated at the time of the survey.