Failure to Document Immunization Education for Cognitively Impaired Residents
Penalty
Summary
The facility failed to ensure that residents' medical records included documentation that residents' representatives were provided education regarding the risks and benefits of immunizations. This deficiency was identified for two residents with severe cognitive impairment. Resident 21's clinical record showed no evidence that she or her responsible party received education about the risks and benefits of the influenza vaccination before it was administered. Despite a psychiatric note indicating that Resident 21 was awake, alert, and oriented, she was unable to confirm if she consented to the vaccination during an interview. Similarly, Resident 46's records revealed that she signed the consent forms for both influenza and pneumococcal vaccinations, but the forms lacked dates, and there was no evidence that her responsible party was informed about the risks and benefits of these vaccinations. Given Resident 46's diagnosis of dementia and severe cognitive impairment, she was not capable of making informed medical decisions independently. The facility's failure to provide the necessary education to the residents' representatives was confirmed by the infection preventionist during an interview.
Plan Of Correction
1. Facility cannot retroactively provide Influenza vaccine informed consent to resident 21 and 46's representatives. Facility cannot retroactively provide Pneumococcal vaccine informed consent to resident 46's representative. 2. Infection preventionist/designee conducted an audit of the last two weeks of influenza and pneumococcal vaccines given to verify resident representatives were provided the informed consent. 3. Infection preventionist will be re-educated on educating resident representatives on the Influenza and Pneumococcal vaccine informed consents prior to vaccination. 4. DON/designee will conduct random audits of Influenza and Pneumococcal vaccination consent forms weekly x4 and monthly x3. Results of audits will be reviewed by the Quality Assurance Performance Improvement Committee and changes will be made as necessary.