Failure to Offer and Document COVID-19 Vaccination: A resident who was severely cognitively impaired and not up to date on COVID-19 vaccination had no EHR documentation showing education, vaccine offer, refusal, or medical contraindication. The facility policy required education and offering COVID immunization to all residents unless medically contraindicated, and the IP/RN acknowledged the vaccine was missed upon admission.
Failure to Educate and Document COVID-19 Vaccination Status: The facility did not document that a resident with a stroke diagnosis who could not make needs known, or the resident's representative, was educated on the risks and benefits of the COVID-19 vaccine or offered/administered the vaccine. Staff interviews also showed that employees were only asked for vaccine status on hire and were not educated on the vaccine, offered it, or directed where to obtain it, despite expectations from the HR Director, DNS, and Administrator.
The facility failed to document COVID-19 vaccine education for two residents reviewed for vaccination status. EHR review showed no evidence that either resident received education on the risks and benefits of the vaccine, and there was no documented consent or declination form. A QA leader stated residents were expected to be offered the vaccine on admission with education and a completed consent/declination form, but this was not done for the two residents.
Failure to offer and document COVID-19 vaccination for two residents. One resident had signed consent for the COVID-19 vaccine, but the EHR showed no proof it was administered. Another resident had previously declined the vaccine, but the record showed no evidence it was offered again after the last refusal. Staff acknowledged the missing documentation and that the vaccine should have been offered again per policy and CDC guidance.
The facility failed to document COVID-19 vaccine education for several residents and failed to annually screen, educate, offer, and record staff acceptance or declination of the vaccine. Records for multiple residents showed no evidence that risks, benefits, and potential side effects were reviewed with the resident or representative, and leadership confirmed staff vaccination status was not formally tracked.
Staff COVID-19 vaccine status was not routinely documented, and education on risks vs benefits plus offering the seasonal vaccine was not shown for 4 sampled staff members, including RNs and NAs. The facility policy addressed resident vaccination but did not include a staff vaccination process, and leadership stated the process for tracking, educating, and offering the vaccine to staff was still being developed.
The facility failed to offer and document COVID-19 vaccine education and consent for two residents with dementia and other significant diagnoses. One resident with moderately impaired cognition and one resident with severe cognitive impairment had records showing influenza vaccine consent, but no documentation that they or their RRs were offered or educated on the risks, benefits, or side effects of the COVID-19 vaccine; the IP confirmed the correct process was not followed.
Failure to Document COVID-19 Vaccine Education and Offer: The facility failed to document COVID-19 vaccine education and offer for 4 staff members and 1 resident. Employee files for several staff members contained no evidence they were educated on the risks vs benefits or offered the vaccine, and a resident's record also lacked documentation of vaccine education or offer. The IP and Administrator acknowledged documentation of vaccine education and consent or declination should be recorded.
Surveyors found that the facility did not maintain required documentation of COVID-19 vaccination status for a CNA, despite a policy stating that staff must provide vaccination records and that the infection preventionist and HR would track and maintain this information. The CNA reported being vaccinated in another state and stated they had given proof of vaccination to the facility. The DON and a regional operations leader indicated that staff vaccination records were kept by HR, but when surveyors requested the CNA’s documentation, no record of the CNA’s COVID-19 vaccination status was produced, resulting in a deficiency related to staff immunization documentation requirements.
Failure to administer consented COVID-19 vaccines to two residents. The facility’s policy required residents to be offered the vaccine and, if they consented, to receive it at the facility or through an outside service. Two residents, including one with diabetes and one with a skin infection, consented to the COVID-19 vaccine, but the EHR had no documentation that either vaccine was administered. An LPN/IP and the DON stated residents should be educated, given the VIS, and vaccinated after consent.
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