Failure to Administer COVID-19 Vaccine After Consent
Penalty
Summary
The facility failed to administer a COVID-19 booster vaccine to a resident after the resident's representative provided verbal consent for vaccination. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis, and cerebral infarction, had moderately impaired cognition and was dependent on staff for activities of daily living. Review of the resident's records showed that the last COVID-19 vaccine dose was administered in 2021, and although consent for a booster was obtained in November 2025, there was no physician order or documentation indicating that the vaccine was ordered or given. Interviews with the Infection Preventionist Nurse (IPN) and the Director of Nursing (DON) confirmed that the resident had not received the COVID-19 booster despite the consent being documented. The facility's policy required offering COVID-19 vaccinations to all residents per CDC and FDA guidelines unless medically contraindicated, already immunized, or refused. The failure to administer the vaccine after obtaining consent constituted a deficiency in following the facility's vaccination protocol.