Failure to Document and Offer Immunizations
Penalty
Summary
The facility failed to obtain and document current immunization status, offer immunizations, and secure consent for flu and pneumonia vaccinations for four out of five residents reviewed. For each resident, clinical records lacked completed and signed consent forms for influenza, pneumococcal, and Covid-19 vaccines. Care plans did not identify any contraindications or allergies to immunizations, and there was no documentation of immunization status in the residents' records. Physician orders for vaccination were not followed up with proper documentation or administration, and the required consent forms remained blank and unsigned. Interviews with nursing staff and the Director of Nursing Services revealed that the facility's process required completion of immunization documentation within 48 hours of admission, with subsequent review and follow-up for missing items. However, this process was not carried out as intended, resulting in missing documentation for immunization status and consent. Facility policies assigned responsibility for informing residents and responsible parties about vaccinations to the Admissions Coordinator, but these procedures were not followed, and no policy for Covid-19 vaccination was provided when requested.