Lack of Documentation for Pneumococcal Vaccine Education
Penalty
Summary
The facility failed to document that education regarding the benefits and potential side effects of the pneumococcal immunization was provided to two residents. One resident, who had diagnoses including COPD and diabetes and was assessed as cognitively intact, initially declined the pneumonia vaccine but later consented and received it. However, there was no documentation in the medical record indicating that education about the vaccine's benefits and risks was provided prior to administration. The Director of Nursing and Assistant Director of Nursing/Infection Preventionist confirmed that the CDC Vaccine Information Statement should have been given, but no documentation of this education was available. Similarly, another resident with COPD and diabetes, also assessed as cognitively intact, declined the pneumonia vaccine initially but later received it. The medical record noted the administration of the vaccine and that the resident tolerated it well, but did not reflect any education provided regarding the vaccine's benefits or potential side effects. During an interview, the resident confirmed consent for the vaccine but reported not receiving any education on its risks or benefits. The DON and ADON/IP acknowledged that education should have been provided and documented, but no such documentation was found.
Plan Of Correction
F883 – Influenza and Pneumococcal Immunizations Element #1: Resident #2 and #22 were assessed to ensure no lasting effects related to insufficient education regarding vaccine administration. Element #2: The Director of Nursing and/or designee conducted a full-house audit to ensure residents receiving immunizations have been provided the appropriate education. Element #3: The Administrator reviewed the policy General Immunization and revised as necessary. Licensed Nurses were provided education on the policy and the need for resident/responsible party education regarding vaccinations. Element #4: The Director of Nursing and/or designee will conduct weekly audits of immunization status for 12 weeks to ensure appropriate education. Results of the audits will be brought to the QAPI Committee monthly for review. Any changes to the auditing process will be determined by the QAPI Committee. The Administrator is responsible to attain and maintain compliance. Compliance Date: 6/20/2025