Deficiency in Vaccination Documentation
Penalty
Summary
The facility failed to provide accurate and timely documentation related to influenza and pneumococcal vaccinations for two residents. Resident R13, who was admitted with diagnoses including high blood pressure, heart failure, and COPD, had no documentation in their clinical record regarding the receipt or refusal of the influenza and pneumococcal vaccines. The Minimum Data Set (MDS) for Resident R13 indicated that the influenza vaccine was not administered, and the pneumococcal vaccine was not documented at all. Similarly, Resident R60, admitted with conditions such as anemia, coronary artery disease, and anxiety, also had incomplete documentation. The MDS for Resident R60 showed that the influenza vaccine was offered and declined, but the pneumococcal vaccine was not offered, and there was no documentation in the clinical record. During an interview, the Infection Preventionist admitted to a lack of participation in the vaccination process and confirmed the absence of a proper documentation process for immunization refusals, leading to the deficiency.
Plan Of Correction
1. Residents experienced no adverse effects. R13 and R60 will be up-to-date with appropriate vaccinations as requested. 2. DON/designee to educate licensed staff on need to offer and document immunizations timely and appropriately. 3. DON/designee will conduct a whole house audit to ascertain if current residents are up to date on immunizations as appropriate. 4. DON/designee to audit new admissions and hospitals returns daily x 1 week, then 3x/week for 3 weeks, and 1x/week for 2 weeks. 5. Results to be submitted to QAPI for review and approval.