Resident Received Duplicate Doses of Vaccines Due to Documentation Failure
Penalty
Summary
A resident with multiple sclerosis and dementia was admitted to the facility and had physician orders for annual influenza vaccination, pneumococcal vaccination every five years, and COVID-19 vaccination. On a single day, the resident was administered two sets of the same three vaccines—pneumococcal conjugate PCV20, high-dose influenza, and COVID-19—within a twelve-hour period. The first set was given in the morning by an RN, and the second set was administered in the evening by an LPN, both documented in the resident's medical record. The LPN discovered the earlier administration only after giving the second set and attempted to document the vaccines, at which point the duplication was identified. The facility's policy required that the individual administering medication document each administration in the Medication Administration Record (MAR) before proceeding to the next. However, the RN failed to document the morning administration in the MAR, leading to the LPN unknowingly administering duplicate doses later that day. This resulted in the resident, who was bedbound and medically frail, receiving double doses of all three vaccines in violation of CDC recommendations for vaccine scheduling. The resident subsequently developed a fever and was sent to the hospital for evaluation.