Failure to Offer and Document COVID-19 Vaccination for a Resident
Penalty
Summary
The facility failed to offer and document COVID-19 immunization for one resident, as required by its policy. According to the facility's policy dated 2023, licensed nurses are to obtain consent for COVID-19 vaccination upon admission and document the immunization history in the resident's electronic health record. A resident admitted with diagnoses including traumatic subarachnoid hemorrhage and anemia, and assessed to have intact cognition, did not have any documentation regarding COVID-19 vaccination or consent in their record. During interviews, facility staff confirmed the absence of vaccine documentation for this resident. These findings were reviewed with facility leadership during the exit conference. No documentation of COVID-19 vaccine education, offer, or status was found for the resident, despite policy requirements and the resident's eligibility.