Failure to Document Immunization Education and Refusal
Penalty
Summary
The facility failed to provide proper documentation and education regarding immunization refusal for one resident among five reviewed for immunizations. Specifically, the resident had refused the RSV vaccine in December 2024, but there was no signed refusal form or progress note in the medical record to indicate that education about the vaccine's benefits and potential side effects had been provided, nor was there documentation of the refusal itself. The electronic medical record contained a blank vaccine consent form with no refusals or signatures, and the Infection Control Preventionist confirmed that the form was not filled out by staff. Further review of the resident's progress notes from late 2024 through mid-2025 revealed no entries regarding RSV vaccine education or refusal, even after the resident was readmitted from the hospital with a diagnosis of RSV following a respiratory illness. The lack of documentation persisted throughout the resident's stay, indicating that the facility did not follow its own policies and procedures for recording immunization education and refusal, as required by regulation.