Failure to Administer and Document COVID-19 Vaccine for Consenting Resident
Penalty
Summary
The facility failed to administer the COVID-19 vaccine to a resident who had provided consent for vaccination. Despite the resident's family member confirming that consent was given, there was no documentation of the vaccine being administered or declined for this resident. The resident was admitted with multiple diagnoses, including cerebral infarction, hyperlipidemia, essential hypertension, chronic atrial fibrillation, insomnia, protein calorie malnutrition, and a history of COVID-19. The infection control nurse and the Director of Nursing both acknowledged that the process for obtaining consent and documenting vaccine administration or declination was not followed for this resident. During a COVID-19 outbreak in the facility, contact tracing revealed that a staff aide who worked directly with the resident tested positive, and the resident subsequently tested positive for COVID-19. The facility's infection prevention and control policy requires identification, recording, and documentation of infections and corrective actions, as well as compliance with public health recommendations. However, the lack of documentation and failure to administer the vaccine as consented represented a lapse in following these procedures for the affected resident.