Failure to Provide and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to minimize the risk of influenza and pneumococcal disease by not ensuring that newly admitted residents and staff were educated on the risks and benefits of immunizations, were provided opportunities to receive immunizations, and by failing to maintain documentation of the information or education provided, the administration of, or the refusal of vaccinations. Specifically, a review of the electronic medical records for four newly admitted residents revealed no documentation of vaccines being received, offered, declined, or contraindicated, nor any indication that education was provided to residents or their representatives. Additionally, there was no documentation related to vaccine monitoring, education, or tracking for either residents or staff, and no line listing or monitoring system was in place. Interviews with facility staff, including the Staff Development Nurse/Infection Control Preventionist Nurse (ICPN) and the Director of Nursing (DON), confirmed the absence of an infection tracking system and the lack of an active Infection Control Program since July 2024. The ICPN admitted to not having any documentation of offering vaccines, resident refusals, or contraindications for the current influenza season, and stated that all previous immunization records could not be found after the departure of the previous ICPN. One cognitively intact resident confirmed that he was never offered any vaccines upon admission and was not provided with information about them. The DON acknowledged awareness of the missing information and suggested that the previous ICPN may have taken or destroyed the documentation.