The facility failed to keep required documentation showing staff were educated on the risks and benefits of the COVID-19 vaccine and that the vaccine was offered to staff who declined it. The IP stated she tracked staff vaccination status, but the record for an CNA showed conflicting information, with a prior dose documented while the tracking log also listed the CNA as refused and left the vaccination date blank. The IP confirmed there was no documentation that the CNA was offered the vaccine or provided the required education.
Missing COVID-19 Vaccination Documentation for Staff: The facility failed to maintain required COVID-19 vaccination records for an CNA, including documentation that the vaccine was offered, information on obtaining it, or verification of vaccination, exemption, or refusal. The IP stated the facility offers COVID-19 vaccine to residents and staff, but the CNA’s file only contained the influenza consent form and no COVID-19 consent or declination documentation. The DON stated COVID-19 vaccination was offered during flu season and, if missed, staff could obtain it through their healthcare provider.
Missing COVID-19 Vaccination Documentation: The facility failed to document COVID-19 vaccine administrations, refusals, and resident education for three residents with diagnoses including schizophrenia/schizoaffective disorder, COPD, diabetes, hypertension, and anxiety. The IPN stated he held vaccine clinics and provided vaccine information sheets, but did not keep records of prior/current doses or specific education in the medical record because he lacked CAIR2 access until recently.
COVID-19 vaccination education, offering, and documentation were incomplete for one resident and several staff members. A resident with no capacity to make decisions had a refusal documented, but the record did not identify the representative who refused the vaccine or the staff member who provided education. Staff records also lacked proof of education for an LPN who declined the vaccine, proof of vaccination for a CNA vaccinated outside the facility, and verification of vaccination status for two newly hired staff members.
Failure to offer the updated COVID-19 vaccine to a resident after an earlier refusal. A resident with COPD and DM had previously refused the vaccine, but the IP did not offer the updated dose when it became available, believing the resident did not want any further vaccines. The record also lacked documentation or a care plan addressing refusal of all further vaccinations, despite facility policy requiring education and offering of vaccine doses to residents and staff as soon as available.
Failure to Offer and Document COVID-19 Vaccination Education: The facility did not provide, offer, or document COVID-19 vaccine education for four residents, as confirmed during record review with the IPA. The IPA, AC, and DON stated the vaccine should be offered on admission, residents should receive education on risks and benefits, and the education should be documented in the EHR or medical chart.
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.
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