Failure to Administer COVID-19 Vaccine After Documented Consent on Admission
Penalty
Summary
The deficiency involves the facility’s failure to administer a COVID-19 vaccine to a newly admitted resident despite documented consent and no contraindications or withdrawal of consent. The resident was admitted with diagnoses including heart failure and hypertension, and the admission consent form, signed by the resident’s representative and admissions staff, explicitly authorized administration of the COVID-19 vaccine annually unless medically contraindicated. The consent form indicated “yes” for COVID-19 vaccine authorization, and the space for the last date the COVID-19 vaccine was received was left blank. The admission MDS assessment documented the resident as severely cognitively impaired and recorded that the COVID-19 immunization was not given because the vaccine was not offered. Review of the medical record showed no documentation that a COVID-19 vaccine was administered and no documentation that consent for immunizations had been withdrawn or that the resident had received the COVID-19 vaccine in the recent year. Interviews further confirmed that the vaccine was not provided. The resident’s representative reported that the resident had not received COVID-19 vaccines on admission and that no one from the facility had communicated that the vaccine had been given. The former IC nurse stated that, prior to leaving her position, she had not provided a COVID-19 vaccine to this resident. She explained that new admissions were discussed during the morning meeting, that she was aware the resident had requested a COVID-19 vaccine, and that she had no reason for not administering it. The Administrator reported that new admissions and requested immunizations were discussed in daily morning meetings and that the resident’s representative was uncertain if the resident had received vaccines prior to admission and was going to obtain that information, but there was an expectation that residents receive vaccines as requested.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.