Failure to Document COVID-19 Vaccine Offer and Status
Penalty
Summary
The facility failed to provide accurate and timely documentation regarding the offering of the COVID-19 vaccination to two residents. According to the facility's Resident Vaccination Policy, consents, refusals, or medical ineligibility for vaccinations are required to be documented in the electronic health record. For one resident with diagnoses including high blood pressure, depression, and anxiety, the clinical record did not contain documentation that the COVID-19 vaccine was offered, administered, or declined, despite the Minimum Data Set (MDS) indicating the vaccination was not up to date. Another resident, diagnosed with dementia, high blood pressure, and hyperlipidemia, had not received a COVID-19 vaccination since a previous documented dose, and there was no record in the clinical file that the vaccine had been offered or declined since that time. The Infection Preventionist confirmed that the required documentation was missing for these two residents, which is not in compliance with facility policy and regulatory requirements.