Lack of Documentation and Education for Influenza Vaccine Refusal
Penalty
Summary
The facility failed to ensure that a resident and/or their representative received education regarding the benefits and potential side effects of the influenza immunization. Medical record review for a resident with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease showed an order for the influenza vaccine, which the resident refused. However, there was no documentation in the medical record of an influenza vaccine consent or declination form, nor evidence that the required education was provided. The resident was noted to be severely cognitively impaired and required staff assistance with activities of daily living. The DON confirmed that the resident refused the vaccine, but the necessary documentation and education were not present in the record, contrary to facility policy.