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.
A resident with capacity to understand had prior COVID-19 vaccination documented in CAIR, but the medical record did not show the resident was assessed for or offered the seasonal COVID-19 vaccine. The facility’s IP could not find documentation of an offer or assessment during record review, and the DON acknowledged the finding.
A resident with chronic respiratory failure, tracheostomy, G-tube, and ventilator dependence, who lacked decision-making capacity and required total assistance with ADLs, was admitted without being assessed for COVID-19 vaccination status. Review of the immunization record and the facility’s vaccine consent tracker showed no evidence that the COVID-19 vaccine was offered, administered, or declined. An LVN confirmed there was no related documentation in the clinical record, and the DON acknowledged this was not consistent with the facility’s vaccination policy, which requires admission screening and consent/declination documentation for all vaccines.
A resident with TBI and cognitive deficits, whose responsible party had previously declined COVID-19 vaccination and whose refusal was documented, was later given a COVID-19 vaccine without informed consent. Progress notes showed the RP’s refusal followed by documentation that the vaccine was administered, and the responsible party discovered the vaccination after noticing a bandage on the resident’s arm and being told by nursing staff that the shot had been given. Facility records and administrator notes indicated that an LN acknowledged being responsible for administering the vaccine without consent, contrary to facility policy requiring informed consent and honoring the legal representative’s right to refuse treatment.
A resident with impaired cognition and significant medical conditions did not receive a COVID-19 booster vaccine after their representative provided consent. Despite documentation of consent and facility policy requiring vaccination, no physician order was placed and the vaccine was not administered, as confirmed by both the IPN and DON.
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