Failure to document COVID-19 vaccine education, consent, and refusal for two residents. One resident had a guardian and diagnoses including DM2 and HTN, and another resident had heart disease. The ICN confirmed neither resident received the vaccine and that the chart lacked documentation of education, consent, or refusal, while the DON stated each resident should have had documented education and either vaccine administration or refusal.
Failure to Offer COVID-19 Vaccine to a High-Risk Resident: A resident with COPD and dependence on supplemental O2 had an out-of-date COVID-19 vaccination status, with no record that the 2025-2026 Spikevax vaccine was offered, declined, or contraindicated. The IP confirmed the resident’s HCP should have been contacted for consent, and the resident was identified as being at high risk for COVID-19 complications due to COPD.
Missing COVID-19 Vaccine Documentation for New Hires: The facility failed to maintain records showing that two newly hired staff members were educated about and offered the most recent COVID-19 vaccine. The policy required staff vaccination status to be documented, but one employee file had no vaccine-offer documentation and another employee was not even listed on the tracking spreadsheet. Interviews confirmed that the staff education and offer information was not available in the employee records.
Failure to document COVID-19 vaccine education and offer: The facility did not show that it assessed, educated, or offered the COVID-19 vaccine to five of five staff records reviewed. The DON confirmed the employee health files for CNAs, an LPN, and the Maintenance Director lacked documentation of education, acceptance, or declination, and the facility did not have a staff consent/declination form.
COVID-19 vaccine was administered to a resident with severe cognitive impairment without consent from the resident or health care proxy. The resident’s daughter had told the facility she did not want the vaccine, and the record still showed an order and MAR/nursing documentation indicating the vaccine was given. The DON later acknowledged the vaccine must have been administered without proxy consent.
Failure to administer COVID-19 vaccine after consent was obtained for a resident with acute respiratory failure with hypoxia and cerebral infarction. The resident had no documented COVID-19 immunization, the RR said the vaccine had not been given before admission and requested it, and the DON and IP stated the vaccine should have been provided shortly after consent because the facility had vaccines available.
Failure to offer and document COVID-19 vaccine education for staff: The facility did not have documentation that a dietary aide was offered or educated about the COVID-19 vaccine. The DON reviewed the personnel file and stated he could not find evidence of the offer or education, believed only the flu vaccine was required, and said there was no process to offer and/or educate staff about the COVID-19 vaccine.
Two residents had COVID-19 vaccination documentation deficiencies. One resident with HF initially refused vaccines, later consented to the COVID-19 vaccine/booster, but the EMR did not show the vaccine was administered after consent. Another resident with dementia and DM had a guardian, but the chart lacked documentation that the guardian was educated on the benefits and potential side effects of the vaccine or that consent or refusal was obtained.
Two staff records lacked signed COVID-19 vaccine declination statements and documentation that they received information on the risks and benefits of the vaccine. One RN and another staff member had consent forms marked as declined, but neither form was signed. Interviews showed confusion between the SDC/IP and HR Director about who was responsible for ensuring the forms were completed, and the HR Director stated there was no facility policy for personnel record content or maintenance.
Missing COVID-19 Vaccination Documentation for Newly Hired Staff: The facility failed to maintain evidence that two newly hired staff members had COVID-19 vaccination status documented or that the updated vaccine was offered. Employee files lacked proof of vaccination, documentation of vaccine education, and any signed declination, despite the ADON/SDC stating that vaccine history should be collected at hire and the most recent COVID vaccine should be offered to staff who had not received it.
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Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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