Failure to Offer and Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident or their representative was offered and educated on the COVID-19 immunization, as required by facility policy. Specifically, for one resident with diagnoses including autism, anxiety, and intellectual disabilities, and who had severely impaired cognition, there was no documentation in the medical record of a COVID-19 immunization assessment, education, or a signed consent/declination form for the years 2024 and 2025. The facility's policy required that residents or their representatives be offered the COVID-19 vaccine, receive education on its risks and benefits, and provide consent. Interviews with facility staff revealed that the process for offering and educating about the COVID-19 vaccine was not followed for this resident. The Infection Preventionist acknowledged that there was no documentation of education or consent from the resident's representative. Although the procedure was to send letters to representatives and follow up if there was no response, staff confirmed that the resident's representative was not contacted after failing to respond to the initial letter. The administrator also confirmed that the correct process was not followed for this resident.