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F0887
D

Failure to Administer COVID-19 Vaccine After Consent

Lancaster, California Survey Completed on 08-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer the COVID-19 vaccine to a resident who had provided informed consent through their responsible party. The resident was admitted with multiple diagnoses, including hemiplegia, hemiparesis following cerebral infarction, unspecified pneumonia, and generalized muscle weakness. Documentation showed that the responsible party consented to the COVID-19 vaccine, and the resident was found eligible for vaccination. However, the immunization report indicated the vaccine was still pending, and interviews with staff confirmed that the vaccine was not administered as required. Staff interviews revealed that after obtaining consent, the process should have included obtaining a physician's order, notifying the pharmacy, and administering the vaccine upon delivery. The infection preventionist, RN, ADON, and DON all acknowledged that the vaccine should have been given and that the process was missed. Facility policy required offering and documenting COVID-19 vaccination for all eligible residents, and the failure to follow up resulted in the resident not receiving the vaccine despite consent and eligibility.

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