F0842

D

Inaccurate Documentation of Third-Party Vaccine Administration on MAR

Cheektowaga, New York Survey Completed on 02-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain accurate and complete medical record documentation regarding vaccine administration for three residents. Facility policies required that residents receive immunizations from a licensed facility nurse per physician orders, that administration be documented on the Medication Administration Record (MAR), and that vaccines given by non-facility staff be entered as historical documentation in the electronic medical record’s immunization module. Policies also required that medications never be out of the sight of the nurse administering them and that nurses document administration on the MAR immediately after giving the medication, observing the five rights of medication administration.

For one resident with Alzheimer’s disease, vascular dementia, and a history of stroke, the MAR for a specified month documented that an LPN administered both a COVID-19 vaccine and an influenza vaccine on a particular date. The Immunization Audit Report showed both vaccines as completed on that date, with incomplete documentation of the COVID-19 vaccine location and administrator, and the influenza vaccine recorded as given in the left deltoid by the Assistant Director of Nursing/Infection Preventionist. For a second resident with dementia, encephalopathy, and COPD, the MAR documented that another LPN administered both COVID-19 and influenza vaccines on the same date, and the Immunization Audit Report showed both as completed, but with incomplete information on the injection site and who administered them. For a third resident with psoriatic arthritis, COPD, and depression, the MAR documented that the same LPN administered an influenza vaccine on that date, and the Immunization Audit Report showed the influenza vaccine as completed in the left deltoid with the administrator field incomplete; this resident was documented as having refused the COVID-19 vaccine.

Interviews established that an outside clinic/pharmacist, not facility nurses, actually administered the influenza and COVID-19 vaccines during a Flu/COVID clinic. The Assistant Director of Nursing/Infection Preventionist stated that the pharmacist administered the vaccines and that the correct order type in the electronic medical record should have been “Outside agency Medication/Vaccine Administration,” not a standard MAR medication order. One LPN reported that the outside agency did not have MAR access and that, after verifying which vaccines residents received, they signed the MAR, even though they generally do not sign for medications they did not administer and did not witness one resident’s vaccinations. Another LPN stated they did not administer any vaccines that day and were only entering orders, despite being listed on the MAR as the administering nurse. Other nursing staff and leadership stated that nurses should not document administration of medications they did not give or did not witness, and the Administrator confirmed that nurses should not sign for medications they did not prepare or administer. Despite this, the MAR and immunization records reflected facility nurses as the administering staff or left the administrator field incomplete, while the vaccines were actually given by a third party, resulting in inaccurate medical record documentation.