Failure to Administer COVID-19 Vaccine as Ordered
Penalty
Summary
Facility staff failed to administer the COVID-19 immunization as ordered for one resident with multiple diagnoses, including Type 2 Diabetes Mellitus, Congestive Heart Failure, and Alzheimer's Disease. The resident was admitted with severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 04. The resident's medical record showed that the last COVID-19 booster was received in September 2022, and a physician's order was placed on February 19, 2025, for administration of the Comirnaty COVID-19 vaccine. However, review of the Medication Administration Record (MAR) for that date showed no documentation that the vaccine was administered. Staff interviews revealed that the Infection Preventionist was unaware of the vaccine order for the resident and did not have documentation of its administration. The facility's process requires obtaining consent from the resident or responsible party before administering the vaccine, but there was no evidence that this process was completed or that the vaccine was given as ordered. The deficiency was identified through record review and staff interviews, confirming a failure to follow the facility's Infection Prevention and Control Program and physician's orders regarding COVID-19 immunization.