Failure to Document COVID-19 Vaccine Education and Status for Residents and Staff
Penalty
Summary
The facility failed to properly document the administration or refusal of the COVID-19 vaccine and the provision of education regarding its benefits and potential side effects for both residents and staff. For three out of five residents reviewed, there was either no documentation of vaccine education, no record of consent or refusal, or incomplete consent forms lacking signatures or identification of the responsible party. In one case, a resident's family member verbally declined the vaccine, but the consent form only had the word 'verbal' written on the signature line without the family member's name, and there was no documentation of education provided. Another resident, who was moderately cognitively impaired, was reported to have declined the vaccine, but the consent form was unsigned and undated, and the resident stated she was not offered the vaccine. For a third resident, there was no documentation of vaccine education, consent, or refusal in the medical record, and the facility could not provide evidence of these actions. Additionally, the facility was unable to provide evidence of COVID-19 immunization status or education for two of five staff members reviewed. The Infection Preventionist stated that she offered the vaccine to residents and recorded verbal responses but did not always obtain signatures, and she did not offer the vaccine to staff but kept records of their immunization status, which were missing for the two staff members in question. The Director of Nursing confirmed that all residents should be offered the vaccine and that documentation of education and consent should be maintained, but acknowledged that records were incomplete or missing.