Failure to Document COVID-19 Vaccine Refusal: A resident with dementia, diabetes, and HTN had severely impaired decision-making and lacked capacity to make decisions. The IPN stated she offered the COVID-19 vaccine to the resident’s RP, who refused, but the refusal was not documented in the health record. The DON stated the declination should have been signed and the refusal documented with the risks and benefits explained and a timeline for reoffering the vaccine.
Failure to Offer COVID-19 Vaccine to Eligible Resident: The facility failed to offer and provide the COVID-19 vaccine to an eligible resident with immune mechanism disorder, CKD, and DM. The resident’s MDS showed moderate cognitive impairment and need for assistance or supervision with multiple ADLs, and the IPN stated the resident had only a historical COVID-19 immunization record and was never offered the vaccine on admission or afterward. The resident also reported there was no documented evidence that the vaccine had been offered.
Failure to Educate and Offer COVID-19 Vaccine to Staff: The facility did not document that two physicians were educated on or offered the COVID-19 vaccine for the respiratory season. Record review with the IPN showed no evidence that either physician received vaccine education or an offer of vaccination, even though both actively cared for residents. Facility policy required COVID-19 vaccine education, offering the vaccine to all staff, and maintaining staff vaccination documentation in personnel files.
Failure to Document COVID-19 Vaccine Education Before Refusal: The facility did not document that two residents were offered education on the benefits and potential side effects of the seasonal COVID-19 vaccine before their refusals were recorded. One resident was competent and had not received the vaccine, while another was cognitively intact, had previously received the vaccine, and was past due for the next dose. The IP reviewed the records and could not find evidence that either resident had been educated before refusing the vaccine.
Failure to document COVID-19 vaccination education and status for 32 of 32 licensed practitioners. The IPN reviewed the COVID-19 staff vaccination binders and stated there was no documented evidence that education on the benefits and side effects of the vaccine had been provided. The IPN also stated licensed practitioners’ vaccination status should be obtained because they have direct access to residents. The DON stated all staff need to be educated and offered the current COVID-19 vaccine, and the facility policy required education on the vaccine’s benefits, risks, and potential side effects for staff.
Failure to Provide COVID-19 Vaccination: A resident with Myasthenia Gravis, asthma, and muscle weakness did not receive the COVID-19 vaccine, and the immunization record showed no documentation of vaccination. The IP confirmed the vaccine was not given and stated she tried to contact the Responsible Party for consent but did not follow up, while the DON stated residents were expected to receive recommended vaccines promptly after admission.
Missing COVID-19 Vaccination Documentation for Licensed Practitioners: The facility failed to maintain documentation of screening, education, offering, and current COVID-19 vaccination status for all licensed practitioners. The IP stated the facility did not document or maintain vaccination status for licensed practitioners, and the DON confirmed records should be maintained for all staff. The facility policy defined staff to include licensed practitioners and stated staff are educated about the benefits, risks, and side effects of the COVID-19 vaccine.
The facility failed to document COVID-19 vaccine screening, education, administration, and/or declination for two physicians. The IPN stated there was no record that the physicians were educated or offered the vaccine, and the DON stated all staff, including physicians, should have been screened for vaccine status. The facility’s staff immunization policy required licensed practitioners to be included and required written consent or declination documentation in the employee medical record.
Failure to Provide COVID-19 Vaccine Education and Staff Declination Forms: The facility did not provide education on COVID-19 vaccine risks and potential side effects for five sampled residents, including residents with diagnoses such as heart disease, dementia, CKD, DM2, dysphagia, and hemiplegia. The DSD stated the facility used a COVID-19 info sheet that did not list side effects and only provided printed education in English. Staff vaccination records also did not include declination forms for employees who declined COVID-19 booster vaccines.
Delayed COVID-19 Vaccination After Consent: A resident with acute respiratory failure, O2 dependence, acute pulmonary edema, and CKD consented to COVID-19 vaccination, but the vaccine was not given within the facility’s 90-day timeframe. The IPN reviewed the record and confirmed the vaccine was administered about 5 months after consent, contrary to the facility’s vaccination policy.
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