Age: 63.0
Sex: M
Vaccine: COVID19
Symptoms: Extra dose administered
Clinical narrative: The client, is a resident at Adult Family Home. He was being seen by the Mobile Vaccine Team on 1/31/2024 and received the updated Spikevax COVID-19 vaccine, however a record review indicates that he also received the updated Comirnaty COVID-19 vaccine on 10/17/2023.   The vaccinator, RN, reports that the client?s POA was present at bedside and answered for the client, who was an unreliable historian. The vaccinator also reports that she inquired about the client?s vaccination history and viewed the client?s CDC COVID-19 Vaccination Record Card as part of the standard pre-vaccination screening process. The pre-vaccination screening indicated that the client had not yet received an updated 2023-2024 COVID-19 vaccine and that this dose was appropriate for the client. After the client passed the other aspects of the pre-vaccination screening and both the client and POA received pre-vaccination education, the vaccinator provided a dose of Spikevax (lot 8059071) to the LD at 1130. The client was observed for 15 minutes and no concerns were noted. The client had been vaccinated using a ?Downtime Form? because EHR had not been available in the field during this vaccination visit. The vaccinator reports that she returned to the main clinic and began to document the vaccination in EHR, but noticed a record in EHR that indicated that the client had also received Comirnaty (Lot H69498) on 10/17/2023. She then brought the discrepancy to the attention of this writer at 1800 on 1/31/24. The next morning, on 2/1/24, this writer investigated and found that the 10/17/23 vaccination was not reflected in EHR. This writer reached out to a subject matter expert to help determine if the vaccination record in EHR was an error, as it contained very little information and was not recorded in EHR. The subject matter expert responded on 2/2/24 and stated that there was a Progress Note pertaining to the 10/17/23 vaccination and that the record was visible because the original vaccinators, Facility, also used EHR.  This writer completed his investigation, determined that it appears that this client did, in fact, receive the updated 2023-2024 Comirnaty COVID-19 vaccination on 10/17/23 in addition to the Spikevax provided by MVT on 1/31/24. This writer contacted the team?s provider, Dr. on 2/3/24, who reported ?no concerns with this rate of re-vaccination?. This writer then reached out to Adult Family home, speaking to a caregiver on site and explaining the situation. The caregiver onsite verbalized understanding and reported that the client had ?seemed fine?. This writer asked that his contact information be given to the client?s POA with a request for the POA to call or email so they could be informed of the situation directly by this writer and any questions or concerns could be addressed.  This writer also spoke with the provider for AFH, to explain the situation and the results of the investigation. During this conversation, the provider reported that his facility had no knowledge of the vaccination on 10/17/23. He called back after a short while to report that he had conducted an assessment of the client and found that he appeared to be to baseline with no concerns noted.