F0887

E

Failure to Educate, Offer, and Document COVID-19 Vaccination for Residents

Lincolnton, North Carolina Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to educate residents on the benefits and potential side effects of the COVID-19 vaccine, to offer the vaccine, and to document vaccination status and related education in the medical record. Five cognitively intact residents were identified whose Minimum Data Set (MDS) assessments showed they were not up to date with COVID-19 immunization and whose records contained no history of COVID-19 vaccination. For each of these residents, there was no documentation that the COVID-19 vaccine had been offered or that education regarding the benefits and potential side effects of the vaccine had been provided.

Resident #3, Resident #16, Resident #99, Resident #117, and Resident #127 were all cognitively intact per their respective MDS assessments and were coded as not up to date for COVID-19 immunization. Record review for each resident revealed no COVID-19 vaccination history and no documentation of an offer of the vaccine or provision of education on its benefits and potential side effects. In interviews, each resident reported not remembering any discussion, offer, or education from the facility regarding the COVID-19 vaccine. Some residents stated they would not want the vaccine, some were unsure, and one resident indicated he would probably take it if it were offered, but these preferences were not documented in the medical record.

Interviews with facility staff revealed systemic process gaps related to COVID-19 vaccination. The Infection Preventionist (IP) nurse stated she offered the COVID-19 vaccine annually and tracked resident interest using a personal list marked with "Y" or "N" but did not maintain formal documentation of consent or declination in the medical record. She reported that the Admissions Coordinator obtained electronic consent forms for influenza and pneumonia vaccines, which were uploaded into the medical record and reviewed by nursing staff, but this process did not include COVID-19 vaccination. The IP nurse acknowledged she did not have a defined process for offering COVID-19 vaccination to new admissions, was unsure if it was consistently offered, and did not provide risk-versus-benefit education, only side-effect education. The ADON reported relying on the IP nurse to manage COVID-19 vaccination, and the Administrator stated he expected all consents, declinations, and vaccinations to be recorded in the residents’ medical records, which was not occurring for COVID-19 vaccines.