Failure to Administer and Document COVID-19 Vaccine for a Resident
Penalty
Summary
The facility failed to provide and document the administration of the COVID-19 vaccine for one resident within 30 days of admission, as required. The resident's clinical record did not contain evidence that the COVID-19 vaccine was administered, nor was there documentation of the resident's COVID-19 vaccine history. Interviews with the Infection Preventionist (IP), Sub-acute Director (SAD), and Director of Nursing (DON) confirmed that although the resident signed a consent form for the COVID-19 vaccine on the day of admission, the vaccine had not been given, and there was no documentation of prior vaccination or a valid reason for not administering the vaccine. The medical record also lacked any completed, active, or discontinued orders for the COVID-19 vaccine, and the immunization record was left blank regarding the resident's COVID-19 vaccine status. Facility policy requires that if a resident requests vaccination or missed earlier opportunities, the vaccine should be offered as soon as possible and all efforts, including each dose administered, should be documented in the medical record. In this case, the facility did not follow its own policy, as there was no documentation of the resident's COVID-19 vaccine administration, history, or refusal. The DON acknowledged that the absence of this documentation made it unclear whether the resident had received the vaccine, and the process for obtaining and recording prior vaccination information was not completed.