Delayed Administration of Influenza Vaccines
Penalty
Summary
The facility failed to ensure that seasonal influenza vaccines were offered and administered in a timely manner to five residents reviewed for influenza immunizations. According to the facility's policy, influenza vaccinations should be offered annually between September 1st (or when vaccines become available) and March 31st. However, documentation showed that all five residents received the 2024-2025 influenza vaccine on March 25th, which was at the end of the designated vaccination period. The records indicated that these residents had been admitted or re-admitted to the facility prior to the administration date, but the vaccines were not offered or given at the beginning of the influenza season as required. An interview with the DON revealed awareness that the former Infection Control Preventionist did not offer the vaccine at the start of the 2024-2025 influenza season. The DON stated that the immunizations were administered in March after discovering the oversight. The clinical records for each resident confirmed the delayed administration of the influenza vaccine, with no evidence that the immunizations were offered or provided earlier in the season as per facility policy and federal requirements.
Plan Of Correction
F 883 Influenza & Pneumococcal Immunizations ELEMENT #1 Residents # 28, 24, 26, 19 and 12 continue to reside within the facility and Influenza vaccinations were administered on 3/25/25 with no negative outcomes. Facility infection control was reviewed and there has not been any confirmed cases of Influenza from March through June 2025. ELEMENT #2 Residents residing within the facility will be educated, offered, and vaccinated with the Influenza vaccine for 2025/2026 when made available and dispensed by pharmacy. ELEMENT #3 The policy, Influenza Vaccine was reviewed and deemed appropriate. The policy, Influenza Vaccine remains in place. The Infection Control Nurse was re-educated on the policy, Influenza Vaccine with emphasis on offering vaccinations in a timely manner. ELEMENT #4 The Director of Nursing and/or designee will conduct random audits of 5 residents to ensure substantial compliance with offering vaccinations. Audits will be conducted weekly for four weeks then monthly for two months. Any concerns will be immediately addressed. The results of the audits will be reviewed by the QAPI committee monthly for 3 months for further recommendations. Any area of non-compliance will be addressed. The Administrator is responsible for sustained compliance. Date of Compliance: 7/8/2025