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F0887
F

Failure to Educate and Document Staff COVID-19 Vaccination Status

Cheney, Washington Survey Completed on 08-20-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and document procedures to ensure staff were educated on the risks, benefits, and potential side effects of the COVID-19 vaccine, and did not maintain records of staff vaccination status. According to the facility's COVID-19 vaccination policy, staff documentation should include education on the vaccine, offering the vaccine or information on obtaining it, documentation of any exemptions, and the vaccination status of staff. However, interviews revealed that a nursing assistant employed for four years did not recall receiving education or information about the COVID-19 vaccine. The Infection Prevention staff confirmed that only influenza and Hepatitis vaccine information was provided to staff, and that COVID-19 vaccination status was not tracked. Further interviews indicated that Human Resources discussed COVID-19 vaccinations only with new employees, excluding long-term staff. The Infection Prevention staff also incorrectly cited HIPAA as a reason for not tracking staff COVID-19 vaccination status. The Director of Nursing was initially unaware of the facility's program for staff COVID-19 vaccinations and later confirmed that ongoing staff were not included in vaccination discussions. These actions and omissions resulted in a lack of education and documentation regarding COVID-19 vaccination for staff, as required by facility policy.

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