Failure to Offer and Educate on Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered and educated on Pneumococcal and Influenza immunizations, as required by their policies. This deficiency was identified during a recertification survey, where it was observed that five residents were not provided with documented evidence of being offered or educated on these immunizations. Specifically, Resident #23 was not offered or educated on the Influenza immunization, and Residents #11, #23, #57, #84, and #93 were not offered or educated on the Pneumococcal immunization. The facility's policies, last reviewed in 2023 and 2024, respectively, require that all residents be educated and offered these vaccines to prevent infections and reduce associated morbidity and mortality. The deficiency was attributed to a lapse in the facility's immunization program due to a personnel transition. The Director of Nursing, who assumed responsibility for monitoring resident immunization statuses after a nurse left the facility, acknowledged falling behind on maintaining the program. This oversight resulted in the sampled residents not being up to date on their immunizations. The report highlights that the facility was unable to provide documented evidence of the residents' immunization statuses or any medical contraindications that would prevent them from receiving the vaccines.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the Influenza vaccine. Education on benefits and potential risk was provided. Consent was received. Influenza vaccine was administered on (MONTH) 17th, 2025. Family and MD were informed. 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Declination was received secondary to resident’s hospice status. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered the Influenza and Pneumococcal vaccine upon admission and annually and provided with educational material for review. An audit of the entire house was completed by the DNS on the Influenza and Pneumococcal Vaccination to ensure that all new admission and readmissions were offered the Influenza vaccine for the 2024-2025 flu season and Pneumococcal Vaccination with signed consent/declination and education on file. All identified issues were addressed (3/26/25). The facility will ensure that each resident that was offered the Pneumococcal and Influenza immunizations will be followed with documented evidence in EMR to validate compliance. III. Systemic Changes: The Policy and Procedure for Conducting the Influenza Vaccination Program for Residents was reviewed by the DNS and found to be in compliance. The Policy and Procedure for Pneumococcal Vaccination for Residents was reviewed by the DNS and found to be in compliance. On 3/31/2025 all RNs and LPNs received in-service/education on ensuring that all residents are offered the influenza vaccine during the flu season and offered the pneumococcal vaccine upon admission if they meet the criteria and documented in EMR. A matrix tracker was created to monitor the Influenza and Pneumococcal vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring, documenting and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Flu and Pneumococcal vaccine, if appropriate, and documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the Influenza and Pneumococcal vaccine upon admission and annually. The DNS will conduct this audit weekly x3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25