Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two of five residents reviewed for immunizations. Specifically, the facility did not offer the COVID-19 vaccine to two residents, as required by CDC guidelines. One resident, under 65 years old with a history of traumatic brain injury and multiple fractures, was cognitively intact and did not recall being offered the COVID-19 vaccine. Review of his electronic medical record confirmed there was no documentation that the vaccine was offered or administered. Another resident, over 65 years old with diagnoses including femur fracture, joint replacement, anemia, dementia, and generalized weakness, had severe cognitive impairment and was dependent on staff for most activities of daily living. There was no documentation in her medical record that the COVID-19 vaccine was offered or administered. Staff interviews confirmed that there was no record of either resident being offered or declining the vaccine, and the DON stated it was the admitting nurse's responsibility to document such offers and refusals.