Failure to Provide and Document Immunization Education and Consent
Penalty
Summary
The facility failed to ensure that education on the risks and benefits of influenza and pneumococcal immunizations was provided to residents or their representatives, and failed to obtain written consent for these vaccinations. In multiple cases, consent forms were either missing, incomplete, or only indicated verbal consent or declination without specifying who made the decision or providing a signature. For example, some forms did not indicate whether the resident or a representative provided consent or declination, and there was no documentation that education was given regarding the vaccines. Several residents with complex medical histories, including conditions such as hypertension, dementia, hemiplegia, Alzheimer's disease, Parkinson's disease, end stage renal disease, and dependence on renal dialysis, were affected by these documentation failures. In some instances, residents received vaccinations despite the medical record indicating a verbal declination, and in other cases, there was no consent form present at all for administered vaccines. The facility's own policies required that education be provided and documented, and that consent or declination be recorded in the medical record, but these steps were not consistently followed. Staff interviews confirmed that the immunization consent forms lacked signatures and did not specify who provided consent or declination. An LPN stated that the previous DON had instructed staff to simply write "verbal" or "verbally" on the forms, which was considered sufficient at the time. This practice resulted in incomplete documentation and a lack of evidence that residents or their representatives were properly informed or had provided written consent for immunizations.