Staff COVID-19 Vaccine Education and Offer Not Documented: The facility failed to document education on the benefits and risks of the COVID-19 vaccine and failed to document that the vaccine was offered to three sampled staff members. Record review showed the employee files lacked evidence of vaccine education or an offer of vaccination, and interviews with the IP, DSD, CNA, and DNS confirmed the facility had not continued offering the vaccine or ongoing COVID-19 education after orientation, despite the facility policy requiring staff education and offering the vaccine.
Failure to Track Staff COVID-19 Vaccination Status and Education: The facility did not maintain a system to monitor staff COVID-19 vaccination status or document staff education on vaccine benefits and potential side effects. An LPN stated the vaccine information was provided and offered yearly, while the IP said the only recordkeeping was in personnel files, relied on staff self-reporting for outside vaccinations, and there was no electronic or handwritten tracker or record of staff vaccine education or screening.
The facility failed to educate and offer the 2025 to 2026 COVID-19 vaccine to 59 of 59 licensed practitioners and did not properly document vaccination status. The IPN stated there was no documented evidence that licensed practitioners received education on vaccine benefits and side effects or that the COVID-19 booster had been offered, and the roster did not include physicians or all staff with direct resident access. The DON stated licensed practitioners need to be educated and offered the current COVID-19 booster for resident safety.
Incomplete COVID-19 Immunization Documentation: The facility failed to maintain complete and accurate COVID-19 vaccine records for three residents. An IP review found one resident’s refusal note did not identify which vaccine was refused and lacked a consent/declination form, another resident had no consent or declination record in the EHR or paper chart, and a third resident’s undated form did not show when education occurred or when the vaccine was declined. The facility’s policy required documentation when a resident refused the COVID-19 vaccine.
Failure to Offer COVID-19 Vaccine to a Resident: A resident admitted with COPD, PNA, and CHF had intact cognition and was not up to date on the COVID-19 vaccine. Record review showed the last COVID-19 vaccine was received in 2024, there was no documentation the vaccine was offered on admission, and an RN stated she had not had time to offer it after the prior infection preventionist resigned. The facility policy required education and offering the COVID-19 vaccine to residents.
Failure to Educate, Offer, and Document COVID-19 Vaccination: A resident with GERD, protein-calorie malnutrition, dysphagia, type 2 DM, and severely impaired cognitive skills was not documented as being educated about or offered the COVID-19 vaccine. Review of both the electronic and physical chart found no evidence of vaccine education, VIS provision, consent, or declination for the resident or RP, despite facility policy requiring these steps.
Incomplete COVID-19 vaccination documentation and screening: The facility lacked documented evidence of staff screening, education, offering, and current vaccination status for several employees, including the Administrator, a Dietary Aide, and the Head Cook. Two residents also had incomplete COVID-19 vaccine consent forms with missing eligibility screening sections; one resident had DM, a foot ulcer, cellulitis, and paraplegia, and the other had leukemia, DM, and keratitis.
Failure to Document COVID-19 Vaccine Offer and History: The facility did not document that a resident was offered the COVID-19 vaccine or obtain the resident’s vaccine history after admission. The IP confirmed the resident was unsure of prior COVID-19 vaccination status because records were at a previous facility, but there was no immunization record, no consent form, and no documentation that the vaccine was offered. The DON stated the facility needed immunization records to avoid double dosing and that vaccine history should have been documented.
The facility failed to educate and offer the COVID-19 vaccine to two LVNs and one CNA reviewed for vaccination status. Facility P&P required employee vaccination assessment, education on non-mandated vaccines, and documentation of declinations, but the IP verified there was no documentation that the staff received screening, education, or an offer of the vaccine. The CNA did not recall receiving these steps, and the DSD stated he did not provide them.
Failure to document COVID-19 vaccine refusal education: A resident with intact cognition and a history of malnutrition and prior antineoplastic chemotherapy refused the COVID-19 vaccine, but the IP could not find documentation that the risks and benefits of refusal were explained. The DON stated the refusal should have been documented and the vaccine offered yearly, consistent with facility policy requiring resident education on benefits, risks, and side effects before vaccination.
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