Failure to Document and Administer Required Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that required pneumococcal vaccinations were properly administered and documented for three out of five sampled residents reviewed for immunizations. For one resident with severe cognitive impairment, the responsible party had consented to the vaccine, but when the resident refused, there was no documentation of the refusal date, nor evidence that the responsible party or the resident received education on the risks and benefits of refusal. Another resident, also with severe cognitive impairment, had a documented refusal of the vaccine, but the record did not specify if education was provided to the resident or their representative. For a third resident with multiple diagnoses including diabetes, schizophrenia, and Alzheimer's disease, the record indicated an order for the vaccine but lacked documentation verifying administration or refusal. Interviews with the Assistant Director of Nursing (ADON) revealed that while refusals were typically noted, there was a lack of consistent documentation regarding the date of refusal and whether education was provided to residents or their responsible parties. The facility's policy required that all residents be assessed for vaccine eligibility and offered the vaccine within 30 days of admission, with refusals and related education to be documented in the medical record. However, the records reviewed did not consistently meet these documentation requirements, leading to the identified deficiency.