Failure to Educate, Offer, and Document COVID-19 Vaccination Status
Penalty
Summary
The facility failed to educate and offer the COVID-19 vaccine to a resident upon admission and did not maintain proper documentation regarding the resident's vaccination status. Specifically, the resident's medical record lacked evidence that the COVID-19 vaccine was offered, refused, administered, or contraindicated, and there was no documentation of vaccine education or previous vaccination history. Staff interviews confirmed that the admitting nurse is responsible for discussing and offering vaccines on admission, and that all relevant information should be entered into the resident's medical record. However, the Assistant Director of Nursing verified that the resident's electronic medical record did not contain any documentation related to the COVID-19 vaccine, and the Administrator confirmed that required consent/refusal forms, education, and administration details were missing from the resident's chart.