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This is VAERS ID 955532

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/22/2021

VAERS ID: 955532
VAERS Form:2
Age:51.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-12
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Posture abnormal, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus SoloStar; Atorvastatin Calcium; Gabapentin; Potassium Chloride ER; Levothyroxine Sodium; Alogliptin Benzoate; Acetaminophen; Milk of Magnesia; Enema Rectal; Bisacodyl Rectal Suppository; Tramadol HCl; Ceftriaxone Sodium; Santyl Exter
Current Illness: Cellulitis of RLE, S/P wound debridement
Preexisting Conditions: HTN, Morbid obese, Diabetes, Hypothyroidism, HTN
Allergies: NKA
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: COVID 19 Vaccination administered by pharmacy staff. No adverse effect at the present time. Staff will continue to observe adverse reaction. Will continue to monitor. Patient at start of shift awake in the bed. Pt at 3am was on the commode leaned to the side. Patient body still warm to touch no pulse. Called for assistance Asap. Cpr started promptly. Cpr given patient on floor 911 arrived at the scene at 3:10am Cpr rotated Between Nursing and EMT on Scene. Cpr was given to patient for over 45 minutes. Patient was pronounced at the scene at 3:50am. Call placed to Pt family by supervisor on shift. MD to be notified. AT 3:00am, I was notified by the nurse that resident is unresponsive. Upon entering room, resident was sitting on the commode unresponsive with absent respiration and pulse. Resident lowered down on the floor with 4 person assist. CPR initiated, AED pads placed on chest with no shock indicated. 911 called and EMT and paramedics arrived around 3:10am. ACLS performed until code stopped and pronounced death at 3:48am. I called and notified family member of his demise and awaiting for family to call us back for funeral arrangements.


Changed on 5/7/2021

VAERS ID: 955532 Before After
VAERS Form:2
Age:51.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-12
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Posture abnormal, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus SoloStar; Atorvastatin Calcium; Gabapentin; Potassium Chloride ER; Levothyroxine Sodium; Alogliptin Benzoate; Acetaminophen; Milk of Magnesia; Enema Rectal; Bisacodyl Rectal Suppository; Tramadol HCl; Ceftriaxone Sodium; Santyl Exter
Current Illness: Cellulitis of RLE, S/P wound debridement
Preexisting Conditions: HTN, Morbid obese, Diabetes, Hypothyroidism, HTN
Allergies: NKA NKA
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: COVID 19 Vaccination administered by pharmacy staff. No adverse effect at the present time. Staff will continue to observe adverse reaction. Will continue to monitor. Patient at start of shift awake in the bed. Pt at 3am was on the commode leaned to the side. Patient body still warm to touch no pulse. Called for assistance Asap. Cpr started promptly. Cpr given patient on floor 911 arrived at the scene at 3:10am Cpr rotated Between Nursing and EMT on Scene. Cpr was given to patient for over 45 minutes. Patient was pronounced at the scene at 3:50am. Call placed to Pt family by supervisor on shift. MD to be notified. AT 3:00am, I was notified by the nurse that resident is unresponsive. Upon entering room, resident was sitting on the commode unresponsive with absent respiration and pulse. Resident lowered down on the floor with 4 person assist. CPR initiated, AED pads placed on chest with no shock indicated. 911 called and EMT and paramedics arrived around 3:10am. ACLS performed until code stopped and pronounced death at 3:48am. I called and notified family member of his demise and awaiting for family to call us back for funeral arrangements.


Changed on 5/14/2021

VAERS ID: 955532 Before After
VAERS Form:2
Age:51.0
Sex:Female
Location:New Jersey
Vaccinated:2021-01-12
Onset:0000-00-00
Submitted:0000-00-00
Entered:2021-01-19
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (PFIZER-BIONTECH)) / PFIZER/BIONTECH EL0142 / 1 LA / IM

Administered by: Senior Living      Purchased by: ??
Symptoms: Cardioversion, Death, Posture abnormal, Pulse absent, Respiratory arrest, Resuscitation, Unresponsive to stimuli

Life Threatening? No
Birth Defect? No
Died? Yes
   Date died:2021-01-13
Permanent Disability? No
Recovered? No
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? No
Hospitalized? No
Previous Vaccinations:
Other Medications: Lantus SoloStar; Atorvastatin Calcium; Gabapentin; Potassium Chloride ER; Levothyroxine Sodium; Alogliptin Benzoate; Acetaminophen; Milk of Magnesia; Enema Rectal; Bisacodyl Rectal Suppository; Tramadol HCl; Ceftriaxone Sodium; Santyl Exter
Current Illness: Cellulitis of RLE, S/P wound debridement
Preexisting Conditions: HTN, Morbid obese, Diabetes, Hypothyroidism, HTN
Allergies: NKA NKA
Diagnostic Lab Data: N/A
CDC 'Split Type':

Write-up: COVID 19 Vaccination administered by pharmacy staff. No adverse effect at the present time. Staff will continue to observe adverse reaction. Will continue to monitor. Patient at start of shift awake in the bed. Pt at 3am was on the commode leaned to the side. Patient body still warm to touch no pulse. Called for assistance Asap. Cpr started promptly. Cpr given patient on floor 911 arrived at the scene at 3:10am Cpr rotated Between Nursing and EMT on Scene. Cpr was given to patient for over 45 minutes. Patient was pronounced at the scene at 3:50am. Call placed to Pt family by supervisor on shift. MD to be notified. AT 3:00am, I was notified by the nurse that resident is unresponsive. Upon entering room, resident was sitting on the commode unresponsive with absent respiration and pulse. Resident lowered down on the floor with 4 person assist. CPR initiated, AED pads placed on chest with no shock indicated. 911 called and EMT and paramedics arrived around 3:10am. ACLS performed until code stopped and pronounced death at 3:48am. I called and notified family member of his demise and awaiting for family to call us back for funeral arrangements.

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