Failure to Document Offering of COVID-19 Booster Vaccines
Penalty
Summary
The facility failed to provide accurate and timely documentation regarding the offering of COVID-19 booster vaccines to five residents. According to the facility's policy, immunization status should be established upon admission and vaccines, including COVID-19, should be offered to residents. Clinical record reviews for five residents revealed that each had not received a COVID-19 booster vaccine, and there was no documentation in their records indicating that a booster was offered. The Minimum Data Set (MDS) assessments for these residents showed they were not up to date with COVID-19 vaccinations, and their last recorded vaccinations were dated well before the review. During interviews, facility staff confirmed that COVID-19 vaccines were not being offered to residents and acknowledged the lack of documentation related to the offering of booster vaccines. The residents involved had various medical conditions, including hypertension, diabetes, anemia, heart failure, edema, osteoporosis, chronic pain, epilepsy, cellulitis, and GERD. The deficiency was identified through a combination of policy review, clinical record examination, and staff interviews, all of which confirmed the failure to document the offering of COVID-19 booster vaccines as required.