Failure to Monitor and Document Immunization Status for Flu and Pneumococcal Vaccines
Penalty
Summary
The facility failed to adequately monitor and document the immunization status for influenza and pneumococcal vaccinations for two residents. For one resident with chronic obstructive pulmonary disease, atrial fibrillation, and hypertension, there were inconsistencies in the records regarding vaccination status. The admission record and a spreadsheet indicated refusal or unknown status for the vaccines, while a consent form stated the resident had already received them. The Infection Preventionist Nurse (IPN) was unable to verify vaccination status through the California Immunization Registry and relied on resident or family reports, but no definitive documentation was available in the medical record. For another resident with Type II diabetes mellitus, heart failure, and hypertension, the records also showed refusal or unknown status for the vaccines. The consent form indicated a verbal refusal, but the IPN could not confirm vaccination history through the registry or other documentation. The facility's policy required screening and documentation of immunization status upon admission, but this was not consistently followed, resulting in incomplete medical records for both residents.