Deficiency in Vaccine Documentation and Education
Penalty
Summary
The facility failed to ensure that each resident received the influenza or pneumococcal immunizations as required, specifically for two residents out of five reviewed. The facility's policy, dated 11/24/2024, mandates that all residents or their representatives be offered and provided with these vaccines, with documentation of any refusal and education provided. However, for Resident #8, who had severe cognitive impairment and a Health Care Proxy, there was no documentation that educational material was provided to the proxy or that a declination was completed. Similarly, for Resident #74, who was cognitively intact, there was no evidence that educational material was offered or that a declination was documented. Interviews with facility staff revealed a lack of clarity and responsibility regarding the vaccination process. The Licensed Practical Nurse Manager was not involved in the vaccination initiative and was unsure about the management of vaccine declinations. The Regional Director of Clinical Services, acting as the Infection Preventionist, stated that an automated call was made to inform Health Care Proxies about the vaccine offerings, but it was the Unit Managers' responsibility to obtain consent or declination. This lack of coordination and documentation led to the deficiency identified during the survey.
Plan Of Correction
Plan of Correction: Approved February 18, 2025 1. Resident #8 and #74 will be offered the influenza and pneumococcal vaccination. Declinations and/or consents will be obtained. 2. All residents could potentially be affected. A review of the pneumococcal and influenza immunization status of all in-house residents was conducted to determine if any other residents did not have an up-to-date pneumococcal and/or influenza immunization record. For those residents identified, the Infection Control Nurse / Clinical Care Coordinators provided influenza and pneumococcal vaccine education to the resident/responsible party to obtain consent or declination of the vaccine if not medically contraindicated. Any resident consenting to the vaccine, an MD order will be obtained and the vaccine will be administered and documented as such in the resident’s medical record. 3. The following policy and procedure were reviewed and not revised: Influenza Vaccine and Pneumococcal Vaccination-Residents. Education will be provided to all licensed Nursing Staff. Re-education to include providing influenza and pneumococcal education to the resident/responsible party, obtaining consent/declination, obtaining an MD order if not medically contraindicated, ordering of the vaccine and administration of the vaccine and documentation of administration. Administration, Nursing Administration and the Infection Control Nurse reviewed the process of obtaining the pneumococcal vaccine. 4. Weekly audits x 4, bi-weekly x 2 and monthly until corrected. Random audit of 3 residents to be done every quarter. All new admissions will be offered the vaccinations. Consents or declinations will be obtained. The DON or designee will report the findings to the Quality Assurance Performance Improvement Committee.