Failure to Administer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to properly administer influenza and pneumococcal vaccines, as well as to document education and refusals for these vaccines, affecting four out of five residents reviewed for immunizations. Specifically, the Infection Prevention Nurse reported that she was responsible for educating residents and obtaining consent or refusals, but could not provide documentation of education for residents who refused vaccination. Additionally, it was noted that an outsourced clinic administered the vaccines, but there was a lack of documentation regarding education and refusals, particularly for residents who declined the influenza vaccine during the 2024 influenza season. Medical record reviews revealed that some residents had orders for annual influenza and pneumococcal vaccines and had received education and consented to both, but only received the pneumococcal vaccine. For several residents, there was no documentation of education or offers for the vaccines, despite orders being present. Facility policies required documentation of education and refusals in the medical record, but this was not consistently done, resulting in incomplete records and failure to follow established procedures for immunization documentation and administration.