F0887

D

Failure to Document COVID-19 Vaccination Education and Status for a Resident

Burlington, Vermont Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s process for COVID-19 vaccination education, offering, and documentation for one of six sampled residents. Record review on 03/25/2026 showed that Resident #124, admitted on an unspecified date, had no documentation in the EMR indicating that the resident or representative had been educated about, offered, received, or declined the COVID-19 vaccine. An Immunizations Report from the EMR listed the resident’s COVID-19 vaccination status as “historical” with a date of 12/5/24, but there was no supporting documentation of the immunization itself. During interviews on 03/25/2026, the Infection Preventionist was unable to produce the facility’s Vaccination Review: Consent/Declination SNF Resident Form for this resident and confirmed that documentation of offering education and obtaining consent or declination for COVID-19 vaccination was not available, despite the facility’s written policy requiring written affirmation for declinations, provision of vaccination fact sheets, and informed consent (written or verbal) for all individuals being vaccinated.

This lack of documentation for Resident #124’s COVID-19 vaccination education, offer, consent/declination, and administration status constituted the cited deficiency.