COVID-19 Vaccine Administered Without Required Consent
Penalty
Summary
The deficiency involves the facility’s failure to obtain consent for administration of a COVID-19 vaccine to a resident whose responsible party (RP) had previously declined vaccination. The resident, admitted with diagnoses including traumatic brain injury and cognitive deficit affecting decision-making ability, had an RP who was documented in a progress note dated 4/30/21 as having declined the COVID-19 vaccine after speaking with a licensed nurse (LN 3). The facility’s COVID-19 vaccine policy stated that residents or their legal representatives have the right to accept or refuse the vaccine, that informed consent must be obtained, and that refusals must be documented in the medical record. Despite the documented refusal, a subsequent progress note dated 5/4/21 indicated that the resident received a COVID-19 vaccine that morning. The RP later reported that the resident returned from a physician’s appointment with a bandage on his arm and stated he had been given a COVID-19 vaccine, and that an unidentified nurse acknowledged and apologized that the vaccine had been administered. Email correspondence from the current Administrator, referencing notes from the previous Administrator, indicated that the vaccine had been given without consent from the RP, and that LN 4 stated she was responsible for the vaccine being administered without consent from either the RP or the resident. This sequence of events resulted in the resident receiving a COVID-19 vaccine contrary to the RP’s documented refusal and without required informed consent, in violation of the resident’s RP’s right to make health care decisions.
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