Failure to Document COVID-19 Vaccination Status for Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure proper documentation of COVID-19 immunization status for three out of five residents reviewed. Specifically, the medical records for these residents did not contain any evidence that they were offered, received, or declined the COVID-19 vaccine. This lack of documentation was found despite the facility's policy requiring that each resident's medical record include information about vaccine education, administration, or refusal. The residents involved had significant medical histories, including conditions such as pulmonary embolism, pneumonia, respiratory failure, diabetes, heart failure, enterocolitis, COPD, cellulitis, and sepsis. All three residents were assessed as cognitively intact according to their Brief Interview for Mental Status (BIMS) scores. Upon review of their electronic medical records, surveyors were unable to locate any documentation regarding COVID-19 vaccination offers or decisions at the time of admission. During interviews, the Assistant Director of Nursing (ADON) indicated a misunderstanding of the requirement, believing that vaccination status did not need to be addressed for short-term residents and was unaware of the need to ask about vaccination at admission. The ADON stated that consents were only obtained after the surveyor's inquiry and that the facility was in the process of arranging another vaccination clinic. No evidence was provided to show that the residents were offered or refused the vaccine at admission prior to the surveyor's request.