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F0883
D

Failure to Administer Influenza Vaccine

Northumberland, Pennsylvania Survey Completed on 12-06-2024

Penalty

1 days payment denial
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to offer and administer an influenza immunization to one of the five residents reviewed for immunizations, specifically Resident 3. According to the facility's policy, residents without medical contraindications should be offered the influenza vaccine annually between October 1st and October 31st. However, a review of Resident 3's clinical records revealed no evidence of receiving the influenza vaccine for the 2024-2025 season, despite having received it in previous years. The facility's policy also requires documentation of vaccine education and informed consent or refusal, which was missing in Resident 3's records. During interviews, Employee 8, a registered nurse and infection control prevention coordinator, confirmed the absence of documentation regarding the administration or declination of the vaccine for Resident 3. The facility could not produce an informed consent for the 2024-2025 influenza vaccine, nor evidence of any contact with Resident 3's responsible party to obtain consent or refusal. This lack of documentation and failure to follow the facility's vaccination policy led to the identified deficiency.

Plan Of Correction

1. Resident 3 family contacted to see if they receive consent if they want the influenza vaccine. 2. Infection Control Preventionist (IP) /designee to do audit to make sure that all consents for influenza for current residents have either been received back or contact to determine administration. 3. DON/Designee will educate Infection Control Preventionist (IP) on 483.80(d)(1)(2). 4. Infection Control Preventionist (IP)/Designee will do an audit weekly x4 and monthly x3 to make sure new residents have determination of influenza vaccine. Results of the inspections will be submitted to the QAPI team. 5. Date of compliance 1/30/25.

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