Failure to Offer and Accurately Document COVID-19 Vaccination and Falsification of Consent Records
Penalty
Summary
The deficiency involves the facility’s failure to offer COVID-19 vaccinations and to accurately document COVID-19 vaccination status for four of five residents reviewed for immunizations. During an interview, the Infection Preventionist/LPN (V25) stated that infection control policies are reviewed annually and that the first positive COVID-19 case in the facility’s current outbreak occurred on February 26, 2026. While reviewing immunization records, V25 reported that certain residents had previously received COVID-19 vaccines in 2024 and that some had refused subsequent doses, but acknowledged that these refusals were not documented in the residents’ immunization records as required. Resident interviews conflicted with the documentation and staff statements. One cognitively intact resident (R25), with diagnoses including hypertensive heart disease without heart failure, lymphedema, multiple sclerosis, and reduced mobility, stated that staff had not offered a COVID-19 vaccine since 2024 and that the resident would have accepted it if offered, including an upcoming dose that had just been mentioned. Another cognitively intact resident (R103), with diagnoses including idiopathic gout, type 2 diabetes mellitus, hypertension, heart failure, osteoarthritis, and stage 3 chronic kidney disease, stated that the vaccine was only offered on the day of the survey and denied that staff had offered the COVID-19 vaccine during the previous year or during the recent outbreak. Further review revealed issues with documentation and consent forms. Shortly after the resident interviews, V25 provided four COVID-19 vaccine consent forms for residents reviewed for immunizations, all bearing dates in 2025. When questioned, V25 admitted not having spoken with these residents that day about vaccines and that only hallway rounds had been done. The residents reported signing the consent forms that day, not in 2025, and denied signing any prior COVID-19 vaccine consents. V25 then admitted to completing the consent documents on the day of the survey, falsifying and tampering with them by adding 2025 dates, and acknowledged that refusals had been verbal only and not documented in the charts. These actions were inconsistent with the facility’s written policies requiring an updated vaccination program for COVID-19 and encouraging staff and residents to remain up to date with recommended COVID-19 vaccine doses.
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