Documentation Failures in Vaccination Records
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the influenza and pneumococcal vaccinations for two residents. Resident R101, who was admitted on 5/9/19, had a Minimum Data Set (MDS) dated 12/9/24 indicating diagnoses of high blood pressure, anemia, and arthritis. The MDS noted that the influenza and pneumococcal vaccines were offered but declined. However, upon review of Resident R101's clinical record on 2/13/25, there was no documentation of a refusal consent form or evidence that education regarding the vaccines was provided. Similarly, Resident R133, admitted on 11/23/20, had an MDS dated 1/19/25 showing diagnoses of high blood pressure, chronic pain, and visual loss. The MDS indicated that the influenza vaccine was offered but declined, while the pneumococcal vaccine was not offered. A review of Resident R133's clinical record on 2/13/25 revealed missing documentation for the pneumonia vaccination consent form, influenza declined consent form, and proof of education provided. The Infection Preventionist confirmed these documentation failures during an interview.
Plan Of Correction
1. Signed declination forms were obtained for R133 and R101. 2. Infection preventionist will do an audit of residents in the last 30 days to ensure influenza and Pneumococcal vaccine was offered if indicated and documented. 3. Director of nursing or designee will in-service licensed staff on offering influenza and pneumococcal vaccines and placing completed consent/declination forms in permanent medical record. 4. Director of nursing or designee will audit 5 residents weekly for 2 weeks, then 3 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure signed consent/declination is present for influenza and pneumococcal vaccines. Audit findings will be shared with QAPI committee.