Failure to Offer, Educate, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that COVID-19 vaccines were offered to residents, that education regarding the vaccine was provided, and that vaccination status and consent were properly documented. Medical record reviews for four residents with significant cognitive impairments and multiple comorbidities revealed no evidence that the COVID-19 vaccine was offered or administered as consented to, nor that education was provided to the residents or their representatives. In one case, there was no documentation of the vaccine being offered or education provided. In two other cases, consent forms were signed, and physician orders were present, but there was no evidence the vaccine was administered. In another instance, the consent form was incomplete, lacking a date and indication of the resident's decision. Interviews with the DON and nursing staff confirmed the absence of documentation and incomplete consent forms. Facility policy required that residents be offered the COVID-19 vaccine and that administration be documented in the medical record, but these requirements were not met for the affected residents. The deficiencies were identified through medical record review, staff interviews, and policy review, affecting four out of five residents reviewed for COVID-19 vaccination status.