Failure to Document Vaccine Consent and Education
Penalty
Summary
The facility failed to ensure that three of five sampled residents had completed documentation for consent, declination, or proof of education regarding pneumococcal and influenza vaccinations. According to the facility's Infection Control Manual, staff are required to counsel residents or their representatives on the benefits and adverse effects of each vaccine prior to administration and to complete the appropriate vaccine information and consent forms at admission and each time the vaccine is offered. However, record reviews revealed that for one resident, there was no documentation of consent, declination, or education for the pneumococcal vaccine, despite evidence of vaccine administration. For another resident, there was no documentation of consent, declination, or education for either the influenza or pneumococcal vaccines, and no historical record of influenza vaccination. A third resident received the influenza vaccine, but the clinical record lacked documentation of consent, declination, or education for the vaccine. During staff interviews, the DON stated that nurses document vaccine administration in the medical record and that consent and education are provided at admission. However, the DON also confirmed that there was no further documentation available for the residents' vaccines beyond the record of administration. This lack of required documentation for vaccine consent, declination, and education constitutes a deficiency in the facility's implementation of its vaccination policies and procedures.