Failure to Document Staff COVID-19 Education and Vaccination Status
Penalty
Summary
Facility staff failed to document each staff member’s COVID-19 vaccination and education status as required. During the infection control task, the Human Resource Manager (HRM) reported that there was no documentation for employees with longevity and that only new hires initialed an Orientation Acknowledgement form indicating they were given COVID-19 education. However, the HRM could not produce the actual education materials that were purportedly acknowledged by initials for two of two selected new hires. The HRM later provided the facility’s Infectious Disease COVID-19 Preparedness and Response Plan as the education but was unable to provide documentation that all staff had been offered the COVID-19 vaccine or that their vaccination status had been recorded. These findings were confirmed through staff interviews and review of the available records and policies. No specific residents or their medical histories were mentioned in the report, and the deficiency centered on the facility’s failure to maintain complete and verifiable documentation of staff COVID-19 education and vaccination offerings.
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