Failure to Document COVID-19 Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of the COVID-19 vaccination, as well as documentation of consent or refusal for the immunization. Medical record reviews for four sampled residents revealed that there was no evidence these individuals received education about the COVID-19 vaccine, nor was there a copy of a consent or declination form maintained in their records. Each of these residents was noted as not being up-to-date on the COVID-19 vaccination according to their most recent MDS assessments. Interviews with the interim DON and ADON confirmed that no further documentation was available to demonstrate compliance with the facility's own policy, which requires education and signed consent prior to vaccination. The policy also specifies that education should be provided in a language and format understood by the resident or their representative, and that documentation and reporting are overseen by the infection preventionist. Despite these requirements, the necessary documentation was not present for the residents reviewed.