Failure to Document Offering and Education of COVID-19 Vaccination for Multiple Residents
Penalty
Summary
Surveyors found that the facility failed to document that certain residents were offered a COVID-19 vaccine and received required education on its benefits, risks, and potential side effects, as required by 42 CFR 483.80(d)(3). The facility’s policy titled “Covid Protocols Post PHE,” dated 1/5/26, stated that vaccines are administered in accordance with CDC recommendations, that all residents are encouraged to remain up to date with recommended COVID-19 vaccine doses, and that staff and residents will be educated on the risks and benefits of the COVID-19 vaccination and will be offered the vaccination. However, for four of five residents reviewed for immunizations, the clinical records and consent/declination forms did not contain evidence that the COVID-19 vaccine was offered or that education was provided. Resident records showed that one resident admitted with COPD, one with a history of stroke, one with Parkinson’s disease and bipolar disorder, and one with congestive heart failure and diabetes each had a “Resident Influenza/Pneumococcal/Covid-19 Consent Declination” form completed in October 2025 that lacked documentation that the COVID-19 vaccine was offered. Additionally, the “Immunizations” sections of their clinical records, reviewed on 4/10/26 at 11:00 a.m., did not include information that COVID-19 vaccines were offered or declined. During an interview at the same time, the Infection Control Preventionist confirmed that the facility failed to document that these residents were offered a COVID-19 vaccine and that they or their representatives were provided education regarding the benefits and potential side effects of the immunization.
Plan Of Correction
The facility will document that each resident was offered a Covid 19 immunization and the resident or resident's representative was provided education regarding the benefits and potential side effects of immunizations. Resident R 20 is no longer in the facility. Resident R24, R31, R98 will be offered the Covid 19 immunization, and the resident or resident's representative will be provided education regarding the benefits and potential side effects of immunizations. On Admission and annually residents will be offered a Covid 19 immunization, and the resident or resident's representative was provided with education regarding the benefits and potential side effects of immunizations. Education will be provided to the licensed Nursing Staff that resident on admission and annually need to be offered the COVID-19 Immunization provided education regarding the benefits and potential side effects of immunizations.Audits will be completed by the DON/Designee on 10% of facility admission for being offered and educated on side effects of the COVID-19 weekly times four and monthly times twoResults of these audits will be reviewed at the QAPI committee meeting for further recommendations.
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