Failure to Maintain Employee Vaccination Records
Penalty
Summary
The facility failed to maintain an Infection Control Program to prevent the development and transmission of disease among its employees. Specifically, for five employees who had direct care and/or close contact with residents, the facility did not determine eligibility for, provide education on the risks and benefits of, or offer the influenza and pneumococcal vaccinations annually. The New York State Department of Health Center for Health Care Quality and Surveillance form completed by the facility showed no documented evidence of these actions for the employees in question. During interviews, the Infection Preventionist and the Administrator acknowledged the absence of employee immunization files, attributing the issue to the departure of the former nurse educator who was responsible for managing the vaccination process. The Administrator was unaware of the missing vaccination information until the survey.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 Corrective action for the affected residents: Employees A, B, E, F, and J will be provided with education on the risks/benefits of and offered the influenza and pneumococcal vaccines by 5/2/25. Vaccines will either be administered or declinations will be signed. Identification of potentially affected residents: All employees are at risk for this deficiency. All employee health files will be audited for proper documentation (administration or declination) of the influenza and pneumococcal vaccines. All files without appropriate documentation will be completed. Measures to prevent reoccurrence: Education will be provided to the human resource recruiter and the infection preventionist. This will include review of the facility policy, Vaccination Review. Continued compliance: The facility staff will complete the auditing for compliance. All new hire health files will be audited monthly. Results of auditing will be brought to the QA meeting. Audits will continue in place until substantial compliance has been achieved as determined by the QA Committee. The administrator is responsible for compliance.