Failure to Document COVID-19 Vaccine Contraindication Screening
Penalty
Summary
The facility failed to ensure that the assessment for contraindications to the COVID-19 vaccine was documented in the medical record for one resident. According to the facility's policy, residents are to be screened for prior vaccination status and the presence of medical precautions or contraindications before being offered the COVID-19 vaccine, with this information documented in the medical record. For the resident in question, although the COVID-19 Immunization Screening and Consent Form was present in the medical record, the screening questionnaire portion was not completed prior to vaccine administration. The resident did provide verbal consent and received the vaccine, but the required documentation of screening for contraindications was missing. Interviews with facility staff, including the Infection Preventionist, Medical Director, and DON, confirmed that the expectation was for screening and documentation to occur prior to immunization. The Infection Preventionist acknowledged that the resident was screened and had no contraindications, but admitted that this was not documented on the form. The DON also confirmed that the screening questionnaire was not completed as required. The resident had multiple diagnoses, including polyneuropathy, emphysema, severe protein-calorie malnutrition, adult failure to thrive, and acute respiratory failure with hypoxia, but there were no adverse reactions to the vaccine noted.