Failure to Assess and Offer Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly assessed for and offered pneumococcal and influenza vaccinations, as evidenced by the review of clinical records, facility policies, and staff interviews. For all five sampled residents, there was a lack of documentation indicating that the pneumococcal vaccine was assessed, offered, or administered, and in some cases, the influenza vaccine was not offered or documented as received. The Infection Preventionist acknowledged that it was her responsibility to ensure residents were up to date with vaccinations but admitted to not having done so due to being new to the role and busy with other tasks. Specific examples include residents with moderately to severely impaired cognition and multiple comorbidities such as anemia, hypertension, hyperlipidemia, schizoaffective disorder, vascular dementia, and diabetes mellitus. For these residents, records failed to show that vaccines were offered, administered, or refused, and in some cases, there was no assessment of prior vaccination history. The Infection Preventionist also noted difficulties in obtaining consent from responsible parties but did not document attempts or refusals related to the vaccines. Facility policy required that all residents be assessed for vaccination status upon admission and that vaccines be offered if not previously received. However, the review found that these procedures were not followed, as evidenced by missing documentation and lack of vaccine administration or offers. The Infection Preventionist had not completed planned audits to identify and address these gaps, resulting in the deficiency.