Failure to Document and Educate on Vaccination Status
Penalty
Summary
The facility failed to ensure that education regarding the risks and benefits of pneumococcal, influenza, and COVID-19 vaccines was provided to residents, and did not ensure administration or obtain documented declinations for two of five residents reviewed for infection control. Specifically, two residents with significant medical histories, including infection of an amputation stump, cellulitis, depression, and chronic systolic heart failure, could not recall being offered immunizations or receiving explanations about the risks and benefits. There was no documented evidence that these residents had been educated about or offered the relevant immunizations. Interviews with facility staff revealed that the process for new admissions included reviewing immunization status, offering vaccines, and obtaining signed consent or declination, but this process was not documented for the two residents in question. The Infection Preventionist and Director of Nursing both acknowledged the absence of documentation regarding vaccination status for these residents, despite facility policy requiring immunization status to be determined and recorded upon admission or soon after.