Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to offer, administer, or obtain consent or declination for Influenza and Pneumococcal vaccinations for two residents out of five reviewed for immunizations. Both residents had been admitted to the facility and were documented as severely cognitively impaired according to their Minimum Data Set (MDS) assessments. Review of their electronic medical records revealed no documentation of consent, administration, or refusal of the required vaccinations since their admission. During an interview, the facility's Registered Nurse/Infection Preventionist confirmed that there was no documentation available to show that the two residents had been offered or had received the Influenza or Pneumococcal vaccines, nor was there evidence of refusal. Facility policy requires that Influenza vaccines be offered to all residents between October 1 and March 31, and that Pneumococcal vaccination status be assessed within five working days of admission, with all actions documented in the resident's medical record. These procedures were not followed for the two residents in question.