Failure to Provide and Document COVID-19 Vaccine Education, Consent, and Declination
Summary
The deficiency involves the facility’s failure to ensure that when COVID-19 vaccine was available, each resident was properly offered the vaccine, educated on its risks and benefits, and had their decision and education accurately documented in the medical record, as required by facility policy and regulation. The facility’s COVID-19 Vaccine Policy stated that residents who decline vaccination would provide a written affirmation indicating they were offered and declined the vaccine, that vaccination fact sheets would be made available prior to administration, and that informed consent (written or verbal) would be obtained from all individuals being vaccinated. However, the policy did not specify the minimum documentation requirements for the medical record, and in practice, the facility did not consistently obtain or record signed declinations or evidence of education. For one resident reviewed in detail, Resident #3, who had diagnoses including psoriatic arthritis, COPD, and depression and was documented as cognitively intact, the Vaccination Review: Consent/Declination SNF Resident Form showed verbal consent for influenza and a documented decision to decline the COVID-19 vaccine. The declination statement on the form was not signed, and there was no documentation of verbal declination. There was also no evidence in the record that this resident received education regarding the risks and benefits of the COVID-19 vaccine. In interview, Resident #3 stated they wanted to receive the COVID-19 vaccine, reported never receiving written or verbal education about it, and stated they had not signed a declination. An Immunization Audit Report later documented that this resident refused the COVID-19 vaccine on a specific date and that no education was provided. Further review of 34 additional resident Vaccination Review: Consent/Declination forms for residents indicated to have declined the COVID-19 vaccine revealed there were no signed declinations and no documentation that Vaccine Information Sheets or other education on risks, benefits, and potential side effects had been provided to the residents or their representatives. Staff interviews confirmed that when residents declined vaccinations, the declination section of the form should have been completed with a signature or verbal declination notation and that education on risks and benefits should have been provided and documented. The Assistant DON/Infection Preventionist acknowledged responsibility for providing vaccination education but had no evidence that such education was completed, and a former unit manager stated they did not provide vaccination education or obtain consents/declinations for a prior influenza/COVID-19 clinic. Leadership interviews further confirmed expectations that both consent and declination statements be signed when applicable and that risks versus benefits be reviewed prior to obtaining decisions, which did not occur as required in these cases.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Missing COVID-19 Immunization Documentation for Staff and Residents: The facility failed to maintain required COVID-19 vaccine documentation for three staff members and two residents. Staff interviews showed the selected employees reported prior vaccination, but the facility had no records showing vaccine dates or type. For two residents, consent forms indicated they were up to date, but the date fields were blank and the facility had no evidence that immunization status was verified with family or the physician; one resident’s record showed the last COVID-19 vaccine was given years earlier.
The facility failed to keep required documentation showing staff were educated on the risks and benefits of the COVID-19 vaccine and that the vaccine was offered to staff who declined it. The IP stated she tracked staff vaccination status, but the record for an CNA showed conflicting information, with a prior dose documented while the tracking log also listed the CNA as refused and left the vaccination date blank. The IP confirmed there was no documentation that the CNA was offered the vaccine or provided the required education.
A resident was not offered the COVID-19 vaccine and was documented as not eligible because the resident was admitted after flu season. The IP and MD stated the facility held COVID-19 vaccinations from July through September so residents would not have to wait for the updated fall formulation, despite the facility policy stating the vaccine will be offered when available unless medically contraindicated, already immunized, or refused.
Incomplete COVID-19 Vaccine Consent and Declination Documentation: The facility failed to document current COVID-19 booster consent, declination, or administration status for several residents. Records showed one resident with an outdated declination, another with a booster consent lacking a signature date and no proof of the current vaccine, a third with consent but no documentation of administration, and a fourth with a declination but no current booster offer documented. An ADON verified the missing documentation and stated the facility updates immunization status in October.
Failure to Provide Consented COVID-19 Vaccine: A resident signed a VIS acknowledgment and vaccination consent indicating they received education and wanted the COVID-19 vaccine, but the vaccine was not given. The IP confirmed the resident had not received the vaccine and was unsure why it had not occurred.
COVID-19 Vaccination Education and Documentation Deficiency: The facility failed to document staff COVID-19 immunization education and failed to show that two residents were educated and offered the COVID-19 vaccine. One resident had no chart evidence of immunization status, education, or vaccination, while another had a prior COVID-19 vaccine history and a booster refusal, but no further evidence of vaccine offers or education after that refusal.
Missing COVID-19 Immunization Documentation for Staff and Residents
Penalty
Summary
The facility failed to maintain required documentation of COVID-19 immunization status for three staff members reviewed for vaccination records and for two residents reviewed for immunization concerns. The report states that the facility was expected to educate residents and staff on COVID-19 vaccination, offer the vaccine to eligible individuals after education, and document vaccination status, refusals, and related information. Review of the facility policy showed that vaccination information was to be recorded in the resident medical record and that staff vaccination records were to be maintained in the employee medical file, including documentation of vaccine status as indicated by NHSN. For staff, the facility could not provide documentation showing the date or vaccine type of COVID-19 immunizations for Employees 6, 21, and 22. Employee 6 reported receiving COVID-19 immunizations around 2020 with no immunizations since, Employee 21 reported being initially fully vaccinated with no immunizations since 2021, and Employee 22 reported receiving initial COVID-19 immunizations plus one booster around 2022 with no immunizations since then. The facility’s records initially listed the COVID-19 vaccination status of 247 of 249 staff as unknown, and later information showed some staff as fully vaccinated, partially vaccinated, exempt, or not vaccinated, but the facility still had no data showing the date or vaccine type for the selected staff. For residents, Resident 175’s record contained no data showing when she last received a COVID-19 immunization, and her husband signed a consent form stating she was up to date, but the date received field was left blank. The facility had no evidence that immunization status was verified with her husband or physician. Resident 11’s record also had a blank date field on the consent form, even though she refused the vaccine because she had received the current recommended COVID-19 vaccine; however, her immunization record showed her most recent COVID-19 vaccine was given on March 12, 2021. The record contained no evidence that the facility attempted to verify that she had received COVID-19 immunizations per current CDC guidance.
Missing COVID-19 Vaccine Education and Tracking Documentation
Penalty
Summary
The facility failed to maintain staffing documentation of education regarding the risks and benefits of the COVID-19 vaccine and the offering of the vaccine. Review of the facility policy showed staff were to be provided education on the benefits, risks, and potential side effects before the vaccine was offered, and the infection preventionist was to maintain a tracking worksheet documenting staff vaccination status, including whether the vaccine was received or declined. The policy also required documentation that staff were offered the vaccine or information on obtaining it, were provided education, and had verification of vaccination or exemption/delay. During interviews and document review, the infection preventionist stated she tracked staff COVID-19 vaccination status on a log and that the log included staff who received or declined the vaccine. However, the facility’s untitled vaccination document showed CNA 1 had received a third COVID-19 dose on 10/27/21, while the same document also listed CNA 1 as refused with the vaccination date left blank. The infection preventionist verified the facility did not keep documentation showing the vaccine was offered to staff who declined it or that education on the risks and benefits was provided to those staff members, and specifically confirmed there was no documentation that CNA 1 was offered the vaccine or educated on its risks and benefits.
Failure to Offer COVID-19 Vaccine to Eligible Resident
Penalty
Summary
The facility failed to offer a COVID-19 vaccination to one resident, R113, out of five residents reviewed for COVID-19 immunizations. R113’s EMR documented the resident as not eligible for the COVID-19 vaccine, with the reason listed as admitted after flu season. The resident was admitted to the facility on 7/7/2026 with diagnoses of chronic obstructive pulmonary disease, generalized muscle weakness, and hypertension. The most recent MDS showed a BIMS score of 10, indicating impaired cognition. During interviews, the Infection Preventionist stated R113 was not offered the COVID-19 vaccine because the Medical Director had implemented a policy of not offering the current vaccine from July until September so residents would not have a delay in receiving the updated version in September. The Medical Director stated COVID-19 vaccinations were held starting in July so residents would not have to wait to get a booster when the updated formulation for new COVID-19 strains became available in the fall. A facility policy titled COVID-19 Vaccination stated COVID-19 vaccinations will be offered to residents when supplies are available, per CDC and/or FDA guidelines, unless medically contraindicated, the individual has already been immunized during that time period, or refuses the vaccine.
Incomplete COVID-19 Vaccine Consent and Declination Documentation
Penalty
Summary
The facility failed to follow the latest CDC guidance for COVID-19 vaccination by not properly documenting written consent, informed declination, or administration status for four residents. Resident 2 had a declination for a COVID-19 booster documented on 06/14/2024, but the record lacked a current declination for the latest booster. Resident 1 had documentation of a COVID booster received on 06/14/2023 and a consent form for a booster, but the consent lacked a signature date and there was no record that the most current vaccine had been given. Resident 8 had a consent for a COVID-19 booster dated 07/20/2026, but the record did not show that the current booster had been administered. Resident 23 had a documented declination of a COVID-19 booster on 12/18/2024, but the facility did not document a current offer of the booster vaccine. On 07/29/2026, Administrative Nurse D verified the missing documentation and stated the facility uses the month of October to update residents' immunization status. The facility's policy stated that residents would be offered the COVID-19 vaccination when available through the community or a third-party partner, that residents or their representatives would receive education on the benefits and risks, and that refusals would be documented in the medical record.
Failure to Provide Consented COVID-19 Vaccine
Penalty
Summary
The facility failed to provide a COVID-19 immunization to a resident who had consented to receive it. A facility policy titled, COVID-19 Vaccination, stated that all residents would be offered the vaccine, educated about it, and that the DON would follow up with the physician's office when questions arose about prior vaccination history. The policy also stated that residents would be questioned during admission about their COVID-19 vaccine status and offered the vaccine if they had never received it. Resident 4 was admitted to the facility and later signed an Acknowledgement of Vaccine Information Statement (VIS) and Vaccination Consent form indicating they received education and wanted the COVID-19 vaccine. A review of the resident's record showed that no COVID-19 vaccine was provided after the consent was signed. During interview, the Infection Preventionist confirmed that Resident 4 had not received the vaccine and was unsure why it had not occurred.
COVID-19 Vaccination Education and Documentation Deficiencies
Penalty
Summary
The facility failed to ensure residents were educated and offered the COVID-19 immunization unless contraindicated for two residents reviewed for immunizations, and failed to maintain documentation related to staff COVID-19 vaccination education. Review of Resident 3’s clinical record showed the resident was admitted on July 4, 2026, but there was no information in the chart indicating COVID-19 immunization status or whether the resident had been offered COVID-19 immunization education, and there was no evidence the resident received a COVID-19 vaccine. Review of Resident 59’s record showed admission on March 21, 2024, historical documentation of a COVID-19 immunization in 2021, and a COVID-19 booster refusal dated February 2, 2024, but no further evidence that the resident or resident representative had been offered any COVID-19 vaccinations or education since that time. In interview, the Nursing Home Administrator and an RN stated the facility had no evidence of documentation regarding staff COVID-19 immunization education and no practice documenting that education.
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