Failure to Document Immunization Offer and Education
Penalty
Summary
The facility failed to document that a resident was offered influenza and pneumococcal immunizations and that the resident or their legal representative received education regarding the benefits and potential side effects of these vaccines. Facility policies required that all residents be offered these vaccines in accordance with CDC recommendations and that education be provided and documented in the medical record. However, a review of the clinical record for a resident admitted with dementia and high blood pressure showed no documentation that the influenza or pneumococcal vaccines were offered or declined, nor that education was provided to the resident or their representative. The Minimum Data Set assessment indicated the resident had severely impaired cognition, did not receive the influenza vaccine, and was not offered the pneumococcal vaccine. While a nurse's progress note recorded a refusal of the flu vaccine, there was no evidence that the resident's legal representative was informed or educated about the vaccines. The Director of Nursing confirmed these findings, acknowledging the lack of required documentation for both the offer and education regarding immunizations for this resident.
Plan Of Correction
R53's POA will be contacted to offer a pneumococcal vaccine. During next flu season, facility will ensure the POA is notified if resident refuses a flu vaccine. A full house audit of all residents will be conducted to ensure all residents are offered appropriate vaccines and educated accordingly. If residents are not capable of making their own decisions, their legal representative will be notified to offer the vaccines and education. DON or designee will educate the facility IP on maintaining documentation of offering the influenza and pneumococcal vaccines on admission and annually. Facility IP or designee will audit all new admissions for documentation of the influenza and pneumococcal vaccine being offered weekly x 4 weeks, then monthly x 2 months. Results will be reviewed at QAPI and revised as needed.