Failure to Assess and Document COVID-19 Vaccination Status on Admission
Penalty
Summary
Surveyors identified a deficiency in the facility’s process for assessing and documenting COVID-19 vaccination status upon admission. One sampled resident, admitted with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and ventilator dependence, was found to lack capacity to understand and make decisions per the admission History and Physical and the MDS assessment. Review of this resident’s immunization record showed no documentation that the COVID-19 vaccine was offered, administered, or declined. The facility’s 2025–2026 flu, pneumonia, and COVID consent tracker also did not list this resident. During interviews, an LVN who assisted the Infection Prevention Nurse with vaccine data entry confirmed there was no documentation in the clinical record that the resident was offered, declined, or received the COVID-19 vaccine upon admission. The DON stated that not offering vaccines to residents upon admission was not aligned with the facility’s vaccination policy and that each resident should be screened by the Infection Preventionist upon admission. Review of the facility’s vaccination policy, last reviewed in January 2025, indicated that all new residents must be assessed for current vaccination status upon admission and that all vaccinations require consent or declination, with any refusal documented in the medical record. These required assessments and documentation were not completed for this resident.
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