Failure to Document and Offer Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that a resident was provided with pneumococcal vaccination and education, as well as documentation regarding the influenza vaccine. During interviews, the DON/Infection Preventionist confirmed that there was no documentation in the resident's electronic health record indicating that the influenza vaccine was offered, administered, refused, or contraindicated. The resident in question had diagnoses including adjustment disorder with mixed anxiety and depressed mood, and asthma, and had been admitted to the facility without proper immunization documentation. Further review of facility policy revealed that it requires annual offering and documentation of influenza vaccination or refusal, as well as education about the benefits and side effects of immunization. Despite this policy, the resident's record lacked evidence that the vaccine was offered or that education was provided, and the DON acknowledged that the resident should have been given the opportunity to receive the influenza vaccine for the current flu season.