Failure to Offer and Document Annual Influenza Vaccination
Penalty
Summary
The facility failed to ensure that one of five sampled residents was offered the influenza vaccination in accordance with its own policies and procedures. The facility's policy required that all residents without medical contraindications be offered the influenza vaccine annually, with documentation of either acceptance or refusal placed in the resident's medical record. Review of the medical record for the resident in question showed that the last influenza vaccine was administered on 11/4/23, but there was no documented evidence that the vaccine was offered again in the subsequent annual period, nor was there documentation of acceptance or refusal by the resident or their representative. Interviews with the Infection Preventionist (IP), Assistant Director of Nursing (ADON), and Director of Staff Development (DSD) confirmed that the influenza vaccine should be offered annually and that consent forms are used to ensure residents or their representatives are informed of the risks and benefits. However, all parties verified that there was no documentation in the resident's record to show that the vaccine was offered after the last administration. The resident was determined to have the capacity to make medical decisions, and the lack of documentation indicated a failure to follow the facility's established procedures for annual influenza vaccination offers.