Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer influenza and/or pneumococcal vaccines to all residents as required by its own policies. Record reviews and interviews revealed that four out of five residents reviewed for immunizations were neither offered nor refused the flu or pneumonia vaccines for the years 2024 or 2025. For these residents, there was no documentation of vaccine administration, refusal, or contraindication in their medical records. The Director of Nursing (DON) confirmed during interviews that the vaccines were not offered or refused for these residents, and the residents themselves, when cognitively able, also confirmed they had not been offered the vaccines. The affected residents had various diagnoses, including functional quadriplegia, hemiplegia, paraplegia, cerebral infarction, muscle wasting, dysphagia, and vascular dementia. Most were cognitively intact and able to confirm their immunization status. The facility's policies, last revised in 2019 and 2022, require that all residents be offered pneumococcal and influenza vaccines unless medically contraindicated. Despite these policies, the required offers and documentation were not completed for the residents reviewed.