Failure to Document COVID-19 Vaccine Education and Offer for Residents
Penalty
Summary
Surveyors found that the facility failed to follow its COVID-19 Vaccination policy requiring documentation in the medical record of education on risks, benefits, and potential side effects of the COVID-19 vaccine, as well as documentation of each dose administered or the reason for non-receipt (medical contraindication or refusal). Record review for two residents showed no documentation that they were offered the opportunity to accept or decline the COVID-19 vaccine, nor that any vaccine-related education was provided. One resident was readmitted with multiple diagnoses including muscle wasting and osteonecrosis, and another was admitted with multiple diagnoses including osteoarthritis, protein-calorie malnutrition, and dementia, yet neither record contained any entries regarding COVID-19 vaccine education or offer. In staff interview, the Clinical Resource Nurse confirmed there were no records on file related to educating or offering the COVID-19 vaccine for these residents. This deficient practice created the potential for harm when residents were not offered education related to the risks and benefits of receiving the COVID-19 vaccination.
