Failure to Offer, Educate, and Document Consent for Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its policy regarding the offering, education, and documentation of consent for influenza and pneumococcal vaccinations for one resident. During interviews and record reviews, it was found that the resident did not recall being offered the influenza or pneumococcal vaccines. The Infection Preventionist was unable to locate any documentation of consent, education, or administration of these vaccines for the resident. The Infection Preventionist stated she was unsure why the resident had not received the vaccines or the required education, and confirmed that there was no record of these actions in the resident's file. Further review with the Director of Nursing revealed that the facility's process is to review immunizations upon admission, provide education on the importance and benefits of the vaccines, and obtain informed consent before administration. The Director of Nursing emphasized that all education and decisions regarding immunizations should be documented in the clinical record, and if not documented, it is considered not done. The resident's immunization record showed no evidence of the vaccines being offered, administered, or any education or consent being documented for the year in question, which is inconsistent with the facility's stated policy.