Failure to Document Vaccination Status for a Resident
Penalty
Summary
The facility failed to provide accurate and timely documentation related to the Influenza and Pneumonia vaccines for a resident identified as R63. According to the facility's policy, residents or their responsible parties should be asked about prior vaccinations at admission, and this information should be documented in the electronic health record. However, upon review of Resident R63's clinical record, it was found that the resident was admitted to the facility without proper documentation of prior vaccinations. The Minimum Data Set (MDS) indicated that the Influenza and Pneumonia vaccines were not offered to the resident, and the COVID vaccine status was not up to date. Further investigation revealed that the clinical record for Resident R63 lacked documentation of the Pneumonia and Influenza vaccination refusal consent form and evidence that education was provided to the resident. During interviews, the Regional Clinical Director-Infection Preventionist confirmed that there was no documentation showing that Resident R63 received or was offered the vaccinations after admission. This deficiency was identified for one of six residents reviewed, indicating a lapse in the facility's adherence to its vaccination policy.
Plan Of Correction
R 63 has been offered the pneumococcal and influenza vaccines. To identify other residents that have the potential to be affected, the Infection Preventionist/ designee reviewed current residents to validate if they have received the influenza and pneumococcal vaccinations. The medical records will be updated accordingly if they received said vaccinations at an outside setting. Those residents who have not received influenza and pneumococcal vaccinations will be reviewed with the physician for appropriateness to offer. To prevent this from recurring, the RDCS educated the facility IP re: offering vaccinations for residents per policy. To monitor and maintain ongoing compliance, the Infection Preventionist/ designee will review 3 residents weekly x4 then monthly x2 to ensure residents are offered the influenza and pneumococcal vaccinations and that vaccinations are provided and documented accurately and timely. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.