Deficiency in Vaccine Education Documentation
Penalty
Summary
The facility failed to provide evidence that education was given to residents or their representatives regarding the risks, benefits, or side effects of the influenza vaccine. This deficiency was identified for two residents during a review of their clinical records. The facility's policy requires that prior to administering the influenza vaccine, the resident or their legal representative should receive a copy of the CDC's current vaccine information statement and sign a consent form, which should be documented in the resident's medical record. For one resident, the clinical record showed that their representative refused the flu and RSV vaccination, but there was no evidence that the representative was educated on the benefits, risks, or potential side effects of the vaccine. This resident had diagnoses including hypertension, diabetes, and severe dementia. Another resident, who had diagnoses of diabetes, hypertension, and protein-calorie malnutrition, received an influenza vaccine, but again, there was no documentation that education was provided to the resident or their representative. During interviews, the facility's Infection Preventionist stated that they distribute the appropriate Vaccine Information Statement and document consent or refusal in the resident's medical record. However, the Nursing Home Administrator confirmed that the required education and documentation were not provided for the two residents in question, leading to the identified deficiency.
Plan Of Correction
1. R8 and R25 continue to reside in the facility and no adverse effects related to the deficiency as cited. R8 Representative was educated on the benefits, risks and potential side effects of the vaccine and noted on clinical record. R25 Representative gave permission for the Influenza and Pneumococcal vaccine and education of the benefits, risks, or potential side effects of the vaccine is on clinical record and no adverse effects related to this practice were observed. 2. The facility has determined that all residents have the potential to be affected by this deficient practice. A facility wide audit will be conducted by the DON and IP Nurse to provide evidence that education will be provided to Residents and/or their Representatives on the risks, benefits, or side effects of the influenza vaccine with confirmed documented on the individuals clinical record to reflect consent or refusal. All residents will be offered the pneumococcal and influenza vaccines as part of the facility vaccination program. 3. After completion of the facility wide audit by the DON, IP Nurse and Nurse Supervisors by March 14, 2025 all licensed nurses will be educated on the policy and procedure for offering and documenting immunizations. 4. Once the vaccination program has been implemented, an audit will be conducted weekly to ensure residents have been offered the appropriate vaccines and documentation is completed by the DON and/or IP Nurse. Throughout flu season, new resident files will be audited to ensure vaccination documentation is completed and residents and representatives were educated on the benefits, risks, and potential side effects of the vaccine and noted on clinical record. Results of these audits will be discussed at the monthly QAPI meeting for three months for further review and recommendations.