Failure to Document Administration or Refusal of Required Vaccinations
Penalty
Summary
The facility failed to provide required documentation regarding the administration or refusal of influenza, pneumococcal, and COVID-19 vaccinations for four out of five reviewed residents. Facility policies for each vaccine require screening for eligibility, offering the vaccine, and documenting either administration or refusal in the resident's medical record. However, for the residents reviewed, there was no documentation in the electronic medical record of vaccine administration or refusals by the resident or responsible party. Specifically, residents with a diagnosis of type two diabetes were admitted to the facility, but their immunization records lacked any evidence of receiving or refusing the influenza, pneumococcal, and, in some cases, COVID-19 vaccines. During an interview, the Infection Preventionist confirmed that there was no documentation of vaccine administration or refusals for these residents and described a process of checking state vaccination data, but no further information was provided prior to the survey exit.