Failure to Document Immunization Status and Education
Penalty
Summary
The facility failed to ensure that one of five residents reviewed for immunizations had proper documentation regarding education on the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of whether the resident received, refused, or was medically contraindicated for these immunizations. Specifically, the clinical record for this resident did not contain any documentation of pneumococcal and influenza immunization status for the review period. During an interview, the Director of Nursing (DON) confirmed responsibility for the infection control program and acknowledged that the most recent vaccine consent form for the resident was dated several months prior to the review period. The DON also confirmed that there was no evidence that the annual immunization process was followed for this resident, and that documentation of consent, education, and vaccine administration was incomplete.