Failure to Document Pneumococcal Vaccine Screening and Education
Penalty
Summary
The facility failed to ensure that two residents were properly screened for eligibility to receive the recommended pneumococcal vaccination, and that appropriate education and documentation were provided. For one resident, the medical record indicated a refusal of the pneumococcal vaccine, but there was no documentation that the resident's vaccination history had been obtained, eligibility determined, or that education regarding the benefits and potential side effects of the vaccine was provided. Additionally, there was no evidence of a consent or declination form being obtained. For the second resident, the medical record did not indicate whether the resident had received or refused the pneumococcal vaccine, nor did it show that vaccination history was obtained or eligibility determined. There was also no documentation of education provided to the resident or their legal representative, and no consent or declination form was found. The Director of Nurses confirmed that the required forms were missing from both residents' medical records.