Failure to educate and offer COVID-19 vaccination to residents: A resident with dementia and two residents with intact cognition had vaccination consent forms indicating they did not want the COVID-19 vaccine, but the forms lacked evidence that the resident or resident representative was offered education about vaccination. Immunization records showed two residents had no COVID-19 vaccinations, while one resident had received a prior COVID-19 vaccine. One consent form was also unsigned by the resident.
Failure to Offer and Document COVID-19 Immunization: A resident with CAD, HTN, and non-Alzheimer's dementia had no documented review of immunization history, no COVID-19 vaccine status in the EMR, and no evidence that vaccine education, consent, or declination was completed. The IP stated the admission nurse should review immunizations within 24 hours and verify status through MIIC before offering needed vaccines, but the resident's record showed none of this had been done.
COVID-19 Vaccination Consent and Education Deficiencies: The facility failed to administer a COVID-19 vaccine to a resident who had already consented, and failed to document CDC vaccine education for two residents whose sons declined vaccination by phone. The RN responsible for infection prevention stated the facility did not currently have COVID-19 vaccine available and did not mail or document education for family review, while the DON stated residents and resident representatives needed full vaccination education and documentation of understanding.
COVID-19 vaccination status was not assessed, discussed, offered, or documented for two residents reviewed for immunizations. One resident with diabetes and HTN had a last documented COVID-19 vaccine in 2021, but the record lacked evidence of admission assessment, CDC-based discussion, or an offer of the recommended vaccine. Another resident with CAD, HF, and thyroid disease also had no documentation of vaccination assessment, education, offer, or declination. Staff and the DON stated immunizations were expected to be reviewed and documented at admission.
Failure to Offer COVID-19 Vaccination: A resident with HTN, HLD, and malnutrition was documented as overdue for a COVID-19 vaccine, but the medical record had no evidence the vaccine was offered or given. The IP and DON both confirmed the resident had not been offered or received the vaccine, despite expectations that it would have been completed shortly after admission.
Failure to offer and document COVID-19 booster vaccination for a resident with intact cognition and multiple chronic conditions, including AFib, HF, HTN, renal failure, DM, anxiety, depression, and schizophrenia. The resident’s MDS did not show she was up to date, and the EMR lacked evidence of a booster being offered, administered, or refused. The DON confirmed there was no documentation that the resident had been assessed for eligibility or offered the booster.
The facility failed to maintain documentation of COVID-19 vaccination status for all 13 residents and failed to document COVID-19 education and vaccination status for a cook. The DON stated there was no process in place to track resident immunization records, and chart review showed no immunization documentation for any resident. The cook stated he was never asked about his COVID-19 status or given education on the vaccine’s benefits, risks, or side effects, and the DON confirmed there was no documentation that education was offered or declined.
Failure to offer and document COVID-19 vaccination for 4 of 5 residents reviewed. Records for residents with diagnoses including Wernicke’s encephalopathy, encephalitis/encephalomyelitis, seizure disorder, vascular dementia, sepsis, and pneumonia lacked evidence of immunization histories and/or that the resident or RP was offered the COVID vaccine; one resident had consented, but the chart lacked evidence the vaccine was provided. The IP acknowledged the missing documentation and stated nurses were expected to offer vaccines per CDC guidance on admission and annually.
A resident with vascular dementia, depression, bipolar disorder, chronic pain, and PTSD received the COVID-19 vaccine, but the record documented that education was not given. The acting DON stated residents received the VIS in the admission packet, while the NC-B stated new consent and education were provided with each vaccine. The facility policy required a VIS, education, and documentation in the EMR before vaccination.
Failure to document staff COVID-19 vaccination education and status: The facility could not produce vaccination education, screening, administration, or exemption records for 5 reviewed staff members, including an LPN, two NAs, and a laundry aide. Interviews showed mixed accounts of whether education was provided at the facility, with some staff saying they only received information or vaccines through a physician or clinic, while the RN responsible for infection prevention stated staff vaccination records were not retained at the facility.
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