Failure to Properly Screen, Educate, and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that all residents reviewed for immunizations were appropriately screened for eligibility to receive influenza and pneumococcal vaccines. Surveyors found that the facility did not consistently determine the correct vaccine for each resident, did not provide education regarding the specific vaccines for which residents were eligible, and did not ensure that informed consent forms were properly completed and signed. In several cases, residents who were eligible to receive influenza or pneumococcal vaccines did not consistently receive the vaccinations as required. Documentation was often incomplete or missing, with forms lacking critical information such as the type of vaccine offered, the date of administration, and evidence that the CDC Vaccine Information Statement (VIS) was provided. Multiple residents' records showed deficiencies in the consent process. Some residents or their representatives signed blank or incomplete consent forms, and in other cases, forms did not include documentation of eligibility screening, the specific vaccine offered, or confirmation that education was provided. For example, several residents' records included only a verbal consent or lacked any documentation of consent or declination. Additionally, some immunization records documented that vaccines were administered or refused without corresponding consent forms or eligibility screenings, and in some cases, the reason for vaccine refusal was not documented or dated. The facility's policies required annual documentation of consents and declinations, provision of the most current CDC VIS, and assessment for contraindications, but these procedures were not consistently followed. Residents with significant comorbidities, such as chronic heart failure, diabetes, end-stage renal disease, and chronic respiratory conditions, were among those affected by these documentation and process failures. The lack of proper screening, education, and documentation resulted in substandard quality of care and placed residents at increased risk for vaccine-preventable illnesses, as directly stated in the report.