Failure to Document COVID-19 Vaccine Education and Offering for Two Residents
Penalty
Summary
The facility failed to ensure that residents' medical records contained documentation of education, offering, or administration of the COVID-19 vaccination for two of five residents reviewed. Record review showed that one resident was admitted on a specified date, but there was no completed COVID-19 vaccination consent and education form in the facility’s COVID-19 consent and education documentation, indicating the resident was not offered the vaccine. Similarly, another resident admitted on a specified date also had no completed COVID-19 vaccination consent and education form in the documentation provided by the facility, likewise indicating that this resident was not offered the COVID-19 vaccine. During an interview, the Infection Preventionist stated that at the time COVID-19 vaccines were being administered, the powers of attorney for both residents were unavailable to provide consent. The Infection Preventionist reported that one of the residents verbally stated he did not want the vaccination and would have been able to sign a consent form declining the vaccine, but this was not done. The Infection Preventionist confirmed that neither resident had completed COVID-19 consent and education forms and that they should have. In a separate interview, the DON stated that her expectation is that every resident be educated and offered the COVID-19 vaccination, that consent forms are scanned into the chart, and that multiple attempts should be made to contact the POA; she confirmed that neither of the two residents had completed COVID-19 consent and education forms and that they should have.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.