Failure to Obtain Consent and Provide Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to ensure that staff obtained signed consents and provided education to residents prior to administering influenza vaccinations. Clinical record reviews for three residents revealed that, despite receiving the influenza vaccine, there was no documentation of signed consent forms or evidence that education regarding the vaccine's benefits and potential side effects had been provided. The residents involved had varying cognitive abilities and medical conditions, including arthritis, dementia, anxiety disorder, cerebrovascular disease, compromised immune systems, and congestive heart failure. Care plans for these residents indicated the need to follow current guidelines for influenza and pneumonia vaccines, but the required documentation was missing from their medical records. Interviews with facility leadership confirmed the lack of proper documentation and education. The DON acknowledged that the immunization process needed improvement and that the current plan to provide consent and education during IDT meetings was not being consistently followed. The administrator expressed a preference for written consent with signatures rather than verbal consent, and the DON admitted that education was not always provided as intended. The facility's policy required that residents or their legal representatives receive information and education about the influenza vaccine prior to administration, with documentation in the medical record, but this was not consistently done.