Failure to Offer and Document COVID-19 Vaccination for Multiple Residents
Penalty
Summary
The facility failed to follow its COVID-19 vaccination policy by not offering, educating about, or documenting COVID-19 vaccination for five reviewed residents. The written policy dated 7/1/25 required that COVID-19 vaccinations be offered to all residents unless medically contraindicated, that residents be educated in an understandable manner using CDC or FDA information about risks and benefits, that they be given an opportunity to ask questions, and that the facility maintain documentation of vaccination status, education, and refusals in the medical record. Record review for the sampled residents showed no documentation that any of them had been offered or received the COVID-19 vaccine, nor that any education or refusals had been recorded. The affected residents had multiple significant medical diagnoses. One resident had heart failure and kidney disease, another had asthma and kidney disease, another had diabetes and osteomyelitis of the foot, another had heart failure and a history of stroke, and another had stroke, dysphagia, and kidney disease. Despite these conditions, there was no documentation in any of their medical records regarding COVID-19 vaccination offers, administration, or refusals. In an interview, the Regional Nurse Consultant, who also serves as the facility’s Infection Preventionist, stated that he expected COVID-19 vaccinations to be offered on admission or upon resident request, and that all vaccinations, refusals, and related education should be documented in the medical record, which was not reflected in the reviewed records.
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