Failure to Document Education on Influenza Vaccine Risks and Benefits
Penalty
Summary
The facility failed to ensure that a resident received education regarding the potential risks and benefits when being offered the influenza vaccine. According to the facility's own policy, residents or their legal representatives must be provided with information and education about the benefits and potential side effects of the influenza vaccine prior to administration, and this education must be documented in the resident's medical record. For one resident, documentation showed that the flu shot was administered per the resident's direction, but there was no record in either the electronic or paper clinical record that the required education on risks and benefits was provided. Interviews with staff confirmed that the expectation was to provide and document this education, typically using a Vaccine Information Statement (VIS). However, the Infection Preventionist was unable to locate documentation that the education was given to the resident in question, and the Director of Nursing confirmed that such documentation should have been present. This lack of documentation indicated noncompliance with both facility policy and regulatory requirements.