Failure to Document and Offer Pneumococcal Vaccines
Penalty
Summary
The facility failed to offer or document the administration or refusal of the pneumococcal vaccine for two residents, leading to a deficiency in immunization practices. Resident #58, who was admitted with dementia and diabetes mellitus, had a severe cognitive impairment with a BIMS score of 7 out of 15. The facility's records did not indicate whether the pneumococcal vaccine was up to date, and there was no documentation of the vaccine being offered or declined. The Director of Nursing (DON) confirmed that the vaccine had not been administered or offered, and no declination form was available. Resident #41, who had intact cognitive functioning with a BIMS score of 13, was also not properly documented regarding the pneumococcal vaccine. Although the resident's MDS indicated the vaccine was offered and declined, there was no documentation in the electronic medical record or hard chart. The DON was unable to confirm if education about the vaccine was provided after the refusal. The facility's policy required documentation of vaccine history, education, and refusal, but these steps were not followed for the residents in question.
Plan Of Correction
1. Corrective Action of Areas Affected: Resident #58 and #41 were educated by the licensed nurse regarding the NJ Ex Order 26.4b1 and consents, and NJ Ex Order 26.4b1 have been offered and administered as ordered. 2. Other Areas Affected: The Director of Nursing/designee has conducted an initial audit on current residents to validate that the pneumococcal vaccinations were offered. If an eligible resident did not receive the pneumococcal vaccinations, the physician has been notified, orders placed, and consents obtained. 3. Systemic Changes to Prevent Future Occurrences: Licensed Nursing staff have been re-educated by the Director of Nursing/designee on the policies for the pneumococcal vaccinations. 4. Monitoring of Corrective Action: The Director of Nursing/designee will conduct weekly audits on x4, then monthly x2 on all new admissions to validate that the pneumococcal consents and vaccinations were offered. Results of the audit will be reported monthly to the Quality Assurance Improvement Plan Committee.