Failure to Document COVID-19 Vaccine Education and Administration
Penalty
Summary
The facility failed to implement its COVID-19 immunization policies and procedures by not ensuring that a resident's medical record included documentation that the resident or their representative was provided education regarding the benefits and potential risks associated with the COVID-19 vaccine. Record review showed that the resident had a history of heart failure, acute respiratory failure, dementia, cognitive communication deficit, and required personal assistance. The resident had previously contracted COVID-19 and had received her last COVID-19 vaccination in late 2023. However, there was no documentation in the care plan or medical record indicating that education about the COVID-19 vaccine was provided to the resident or her representative during the relevant period. Interviews with facility staff, including the DON and previous ADON, revealed uncertainty about the ongoing administration of COVID-19 vaccines to residents. The resident's responsible party confirmed that consent for vaccination had been given, but the vaccine was not administered, and no education was provided. The facility's policy required that education be provided and documented before offering the vaccine, but this was not followed for the resident in question.