Failure to Provide Immunization Education
Penalty
Summary
The facility failed to provide required immunization education for four out of five residents reviewed for influenza immunizations. Specifically, Residents 11, 15, 46, and 59 received the influenza vaccination for the 2024-2025 season without documented evidence of education regarding the risks and benefits of the vaccination being provided to them or their responsible parties. The vaccinations were administered on various dates in October and November 2024, but the clinical records lacked documentation of the necessary educational information. An interview with Employee 6, the infection control preventionist, confirmed these findings. The absence of documented education for these residents constitutes a failure to comply with the regulatory requirements for immunization education. This deficiency was identified during a review of select facility policies and procedures, clinical record reviews, and staff interviews, highlighting a gap in the facility's adherence to mandated educational protocols for vaccinations.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State or Federal regulatory requirements. 1. Residents 11, 15, 46, and 59 or their responsible party have acknowledged they received education at the time of consenting/declining the influenza immunization. 2. The Infection Preventionist will review all current residents to ensure documentation of influenza education of risks and benefits of vaccination was provided to resident or responsible party. 3. Education for the Infection Preventionist regarding documentation requirement for provided education of the influenza immunizations. 4. Audits for documented education for influenza and pneumococcal to residents or families will be conducted weekly x4 then monthly x2 with results reported in QAPI. 5. Compliance date: January 28, 2025.