Failure to Document Consent and Screening for Influenza Vaccination
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed for influenza vaccination for four of five sampled residents. Specifically, there was no evidence in the medical records of these residents that screening for medical contraindications was performed, education regarding the risks and benefits of the vaccine was provided, or that informed consent or declination was obtained and documented prior to vaccine administration. Staff interviews confirmed that consent or declination forms could not be located for these residents, despite records showing that the influenza vaccine had been administered. A review of the facility's influenza policy indicated that informed consent, provision of the Vaccine Information Statement (VIS), screening for contraindications, and documentation of refusals or contraindications are required steps prior to vaccination. However, for the residents in question, these steps were not documented as completed. The facility was unable to provide the requested documentation during the survey, resulting in a deficiency related to the administration and documentation of influenza vaccinations.