Failure to Document Pneumococcal Vaccine Education and Consent
Penalty
Summary
The facility failed to provide documentation that four out of six residents reviewed had received education and were offered the pneumococcal immunization. Upon review of the medical records for these residents, there was no evidence of education, consent, or declination regarding the pneumococcal vaccine. Both paper and electronic records were checked, and interviews with the ADON and DON confirmed that such documentation should be present if a resident declines the vaccine. However, the required forms could not be located for the affected residents. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine should be offered within 30 days unless contraindicated or previously administered. The policy also requires documentation of education and any refusal in the resident's medical record. The absence of this documentation for the four residents reviewed constitutes a failure to follow established procedures for immunization education and consent.