Failure to Screen, Educate, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were screened for COVID-19 immunization, educated on the risks and benefits of the COVID-19 vaccine, or offered and received the vaccine as required. Record reviews for five residents with various diagnoses, including dementia, schizophrenia, muscle weakness, congestive heart failure, asthma, morbid obesity, diabetes, respiratory failure, and COPD, revealed no documentation of COVID-19 vaccination status, consent or declination, or education provided regarding the vaccine. These findings were confirmed during interviews with the President of Operations and a Regional Registered Nurse, who stated they were unable to locate any vaccination records, refusals, or education documentation for the affected residents in the electronic medical records. CDC guidance reviewed during the survey indicated that everyone over six months of age should receive the 2024-2025 COVID-19 vaccination to protect against circulating strains and prevent severe health outcomes. Despite these recommendations, there was no evidence in the medical records that the five residents had been screened, educated, or offered the COVID-19 vaccine, nor was there documentation of their vaccination status or any refusals.