Failure to Provide Requested COVID-19 Vaccination Due to Breakdown in Ordering Process
Summary
The deficiency involves the facility’s failure to administer a requested SARS-CoV-2 (COVID-19) vaccination to a cognitively intact resident after a provider order was obtained. The resident, admitted with diagnoses including asthma, malnutrition, and vertigo, had previously received four COVID-19 vaccinations, the last in late October 2024. On 12/30/25, the resident requested another COVID-19 vaccination, and the nurse practitioner issued an order on 12/31/25 for a Comirnaty 30 mcg/0.3 mL intramuscular dose. The order was entered with an end date of 01/08/26. On 01/07/26, an LPN documented the vaccine on the MAR as “Med Not Available” and did not administer it. Review of the January and February 2026 MARs showed no evidence that the vaccine was ever given. The resident later developed a cough and was transferred to the hospital after independently calling EMS; she reported being hospitalized for eight days with COVID-19 and double pneumonia. During interview, the resident stated she had been told she would receive the vaccine on 01/07/26 but did not, and was informed it was on back order, with the only alternative offered being to go to a local pharmacy, which she declined due to cold weather. The LPN unit manager did not recall the request but confirmed placing and revising the vaccine order. The LPN who signed the MAR as “Med Not Available” stated the pharmacy required paperwork before sending the vaccine and that she notified someone at the facility, though she could not recall whom. The ADON stated nurses should call the pharmacy to confirm vaccine orders and provide needed information. Pharmacy staff reported the COVID-19 vaccine was not on back order and had been available throughout the relevant months, but the facility had not submitted the required vaccine request form, so the pharmacy could not release the vaccine. Facility policy required that residents be offered influenza, pneumonia, and COVID vaccines unless contraindicated or already vaccinated.
Penalty
Resources
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The facility did not offer or provide the COVID-19 vaccine to staff members, even though the vaccine was available on site. Documentation and staff interviews confirmed that the updated vaccine was not administered to team members, potentially impacting all residents.
The facility did not screen, educate, or offer the COVID-19 vaccine to several residents with complex medical conditions, and failed to document vaccination status, consent, or education in their medical records, as confirmed by facility leadership and record review.
The facility did not provide documented education on COVID-19 vaccine risks and benefits or obtain written consent for immunization for five residents with complex medical conditions. Consent forms were incomplete, often only noting a verbal declination without specifying who made the decision, and lacked signatures. Staff interviews confirmed that written consent and proper documentation were not obtained, contrary to facility policy.
A resident with multiple chronic conditions and severe cognitive impairment was not offered the COVID-19 vaccine as required, and there was no documentation of vaccine consent or declination in the medical record. The DON confirmed the lack of documentation regarding the vaccine offer or administration.
The facility did not ensure all staff received annual education or vaccine information sheets regarding the COVID-19 vaccine, nor did it document that 54 of 79 staff were offered the vaccine as required. Staff were told to obtain the vaccine from outside providers, and only new hires were asked about the vaccine upon employment. This deficiency had the potential to affect all residents.
Several residents with intact cognition and multiple medical conditions were not offered the COVID-19 vaccine, and the facility could not provide documentation of vaccine consent or refusal as required by policy. Interviews confirmed the absence of necessary records for these individuals.
Failure to Offer COVID-19 Vaccine to Facility Staff
Penalty
Summary
The facility failed to ensure that the COVID-19 vaccine was offered or provided to staff members, despite the vaccine being available on site. Review of facility documentation showed that the updated COVID-19 vaccine would not be administered to team members at the facility. This was confirmed during an interview with a corporate registered nurse, who verified that the vaccine was not offered or provided to staff. This deficiency had the potential to affect all 70 residents in the facility, as staff vaccination is a key component in preventing the spread of COVID-19 within the facility. No information was provided regarding the vaccination status of individual residents or staff, nor were any specific medical histories or conditions mentioned in relation to the deficiency.
Failure to Screen, Educate, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were screened for COVID-19 immunization, educated on the risks and benefits of the COVID-19 vaccine, or offered and received the vaccine as required. Record reviews for five residents with various diagnoses, including dementia, schizophrenia, muscle weakness, congestive heart failure, asthma, morbid obesity, diabetes, respiratory failure, and COPD, revealed no documentation of COVID-19 vaccination status, consent or declination, or education provided regarding the vaccine. These findings were confirmed during interviews with the President of Operations and a Regional Registered Nurse, who stated they were unable to locate any vaccination records, refusals, or education documentation for the affected residents in the electronic medical records. CDC guidance reviewed during the survey indicated that everyone over six months of age should receive the 2024-2025 COVID-19 vaccination to protect against circulating strains and prevent severe health outcomes. Despite these recommendations, there was no evidence in the medical records that the five residents had been screened, educated, or offered the COVID-19 vaccine, nor was there documentation of their vaccination status or any refusals.
Failure to Provide COVID-19 Vaccine Education and Obtain Written Consent
Penalty
Summary
The facility failed to provide education on the risks and benefits of COVID-19 immunization and did not obtain written consent for COVID-19 vaccinations for five residents. Medical record reviews for these residents, who had complex medical histories including hypertension, dementia, cerebrovascular disease, dysphagia, chronic kidney disease, Alzheimer's disease, Parkinson's disease, and end stage renal disease, revealed that COVID-19 vaccination consent forms were either not dated, not signed, or only indicated a verbal declination without specifying whether the decision was made by the resident or a representative. There was also no documentation confirming that education on immunization risks and benefits had been provided. Interviews with facility staff confirmed that the consent forms lacked signatures and did not indicate who provided the consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. Review of the facility's policy indicated that resources and counseling on the importance of COVID-19 vaccination were to be offered, but this was not reflected in the documentation for the affected residents.
Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its policy and CDC guidance. Medical record review showed that the resident, who had diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease, was admitted to the facility after having received a COVID-19 booster prior to admission. Despite being severely cognitively impaired and requiring staff assistance with activities of daily living, there was no documentation in the resident's medical record from the time of admission through the review period indicating that the COVID-19 vaccine was offered, declined, or administered. Additionally, there was no consent or declination form present in the chart, and the DON confirmed the absence of such documentation.
Failure to Provide Annual COVID-19 Vaccine Education and Documentation for Staff
Penalty
Summary
The facility failed to ensure that all staff received education and vaccine information sheets regarding the COVID-19 vaccine, as required by policy and CDC/FDA guidelines. Out of 79 staff members, there was no documentation that 54 had been offered the annual COVID-19 vaccine or received education about its risks and benefits. Only 25 new staff hired since September 1, 2024, had received some education and declined the vaccine, but there was no evidence that any staff were provided with the vaccine information sheet. Interviews with staff, including RNs, the Administrator, and the Human Resource Manager, confirmed that the facility did not provide annual education or offer the vaccine to staff, instead instructing them to obtain it from their own pharmacy or physician. Further review of the facility's COVID-19 Vaccine Policies and Procedures indicated that all staff should be offered the vaccine annually and provided with education and a vaccine information sheet, with documentation maintained for all staff. However, the Administrator and HRM acknowledged that staff were only asked about the vaccine upon hire and not annually, and that the required education and information sheets were not provided. This deficiency affected 54 of 79 staff and had the potential to impact all residents, with a facility census of 58 at the time of the survey.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 immunization was offered to residents, as required by policy. Record reviews for four residents with various medical conditions, including cerebral palsy, COPD, heart failure, diabetes, demyelinating disease, paraplegia, asthma, cellulitis, MRSA infection, and altered mental status, revealed no evidence that these residents were offered the COVID-19 vaccine. All four residents had intact cognition according to their Minimum Data Set assessments. Interviews with the Regional Director of Clinical Services confirmed that the facility was unable to locate documentation of COVID-19 vaccine consent or refusal for these residents. The facility's policy required that residents be offered the vaccine, sign consent prior to administration, and that documentation of consent or refusal be retained in the medical record. However, for these residents, there was no such documentation present.
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