Failure to Maintain Documentation of Staff COVID-19 Vaccination Status
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to maintain documentation of COVID-19 vaccination status for a staff member. The facility’s policy, revised in May 2023 and titled “Coronavirus Disease (COVID-19)-Vaccination of Staff,” stated that staff would provide documentation of their vaccination, that the infection preventionist would maintain a tracking worksheet of staff and their vaccination status, and that the facility would maintain documentation related to staff COVID-19 vaccination status. Review of the staff list showed that a CNA, hired on 11/03/2025, was among the staff for whom COVID-19 immunization status was to be documented. During an interview, the CNA stated they had received their COVID-19 vaccination in another state and had provided a copy of their vaccination status to the facility. In a subsequent phone interview, the DON stated that the facility kept COVID-19 vaccination records for staff and indicated that Human Resources (HR) had this CNA’s vaccination record. A regional operations leader also stated that HR staff were not in the building and that they would look in the HR office for the CNA’s vaccination record. By the end of the surveyor’s follow-up on the same day, no information or documentation regarding the CNA’s COVID-19 vaccination status was provided, demonstrating the facility’s failure to produce required documentation in accordance with its policy and WAC 388-97-1620(2)(b)(i)(ii).
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