Failure to Document and Offer Required Immunizations
Penalty
Summary
The facility failed to ensure that eligible residents were offered and appropriately documented for influenza and pneumococcal vaccinations, as required by their own policies and procedures. Specifically, one resident with diagnoses including type 2 diabetes mellitus and acute/subacute respiratory conditions had no documentation of any pneumococcal vaccine being offered or administered, nor any record of refusal or contraindication. The Wisconsin Immunization Registry also did not show any pneumococcal vaccine for this resident, and there was no evidence in the facility records that the vaccine was offered. Interviews with the Nursing Home Administrator and the Director of Nursing confirmed the absence of documentation and indicated that the DON was still familiarizing themselves with the facility's records. Another resident, admitted with severe morbid obesity and pneumonia, had no documentation of being offered or receiving the influenza vaccine for the current timeframe, nor any record of contraindication or refusal. The facility's policies require that residents be assessed and offered these vaccines, with proper documentation in the medical record, including education provided and the outcome of the offer. The surveyor's review found that these requirements were not met for the two residents reviewed, resulting in a deficiency related to immunization practices and documentation.