Failure to Document Pneumococcal Vaccine Refusals and Education
Penalty
Summary
The facility failed to provide adequate documentation regarding the acceptance or refusal of the pneumococcal vaccine for three out of five residents reviewed. For two residents with severely impaired cognition, there was no documentation in the electronic medical record (EMR) of vaccine refusal, and the unit immunization tracking forms indicated declination without specifying dates. Additionally, there was no evidence that education or declination information was provided to the residents or their representatives. For a third resident with intact cognition, the EMR noted a refusal of the PCV13 vaccine, but again, no date was recorded, and the tracking form lacked a date as well. There was also no documentation of education or declination provided to this resident. Staff interviews revealed that attempts were made to contact family members for residents with low cognitive scores, but documentation of these efforts was inconsistent or missing. The Director of Nursing acknowledged that if refusals were not documented in the EMR, they should have been recorded on paper, indicating a lapse in following the facility's vaccination and screening policy. The policy required offering pneumococcal vaccines upon admission to residents who had never been vaccinated or had previously refused, but the facility did not maintain complete records as required.