Failure to Offer and Document Influenza Vaccination for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were offered the influenza vaccine for the 2024-2025 flu season, as required by facility policy and procedure. Interviews with the Infection Prevention Nurse (IPN) revealed that there was no documentation in the residents' medical records indicating that the flu vaccine was either offered, administered, or declined for these residents. Both the electronic health records and the California Immunization Registry were reviewed, and neither resident had evidence of receiving or declining the vaccine for the specified season. Resident 152 had a history of respiratory failure, ventilator dependence, and pneumonia, and was assessed as unable to make decisions or participate in a mental status interview. Resident 441 had diagnoses including respiratory failure and COPD, was also ventilator dependent, and similarly assessed as unable to make decisions. Both residents were dependent on staff for all functional abilities, and their care plans indicated a high risk for infection with interventions to offer and administer vaccines as needed. However, there was no documentation in their care plans, interdisciplinary team meetings, or other records to show that the flu vaccine was offered or declined. Facility policies required that all residents be offered vaccines unless medically contraindicated or already immunized, and that refusals be documented in the medical record. Despite these requirements, the facility was unable to provide documentation that the two residents were offered the flu vaccine or that any declination was recorded, constituting a failure to follow established vaccination protocols.