Failure to Administer and Document Pneumococcal and Influenza Vaccines
Penalty
Summary
The facility failed to administer both the Pneumococcal and Influenza vaccines to one resident, despite having obtained signed consent for these vaccinations. Documentation provided by the Infection Control RN confirmed that the resident had signed to receive both vaccines, but there was no evidence in either the vaccination book or the electronic medical record that the vaccines were actually administered. The Director of Nursing acknowledged the absence of documentation for vaccine administration, even though the expectation was that residents who sign consent forms would receive the vaccines. The resident involved had multiple significant medical conditions, including a history of stroke, chronic obstructive pulmonary disease, hypertension, generalized anxiety, major depressive disorder, dysphagia, and aphasia. The resident was also noted to be severely cognitively impaired. Facility policy required documentation of vaccine administration, including the injection site, in the medical record, but this was not completed. Additionally, the facility was unable to provide the influenza vaccination policy when requested during the survey.