Failure to Ensure Appropriate COVID-19 Vaccination and Documentation
Penalty
Summary
The facility failed to administer appropriate COVID-19 vaccinations in accordance with CDC guidance for one resident. Resident 45 had diagnoses including aortic valve insufficiency, heart disease, and muscle weakness, and a quarterly MDS dated 3/9/26 documented moderately impaired cognition. A COVID-19 vaccine consent and a COVID-19 booster consent were signed by the resident’s representative on 12/6/24. However, a review of the vaccination record showed the resident had not received any COVID-19 vaccination, and the record also indicated that the family representative had refused the vaccination in December 2024. The clinical record lacked an updated or yearly COVID-19 vaccination consent or declination. During interviews, the DON stated she was unable to locate current COVID-19 vaccination forms for this resident and confirmed that the facility did not administer vaccinations directly, instead using an off-site company to provide vaccines. She acknowledged that another vaccine clinic needed to be scheduled but had not yet done so, and also stated that COVID-19 vaccinations were to be offered yearly. The Infection Preventionist reported that residents were offered COVID-19 vaccinations. CDC guidance reviewed by surveyors indicated that adults, including those in LTC settings, should receive an updated COVID-19 vaccine, and that individuals aged 65 and older should receive two doses of an updated vaccine six months apart, with consent required from LTC residents. The deficiency was cited under 410 IAC 16.2-3.1-18(b)(5).
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