Failure to Document and Administer Required Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered, screened, educated, and received influenza and pneumococcal vaccinations as required by both facility policy and CDC guidance. This deficiency was identified through record reviews, policy reviews, and staff interviews, affecting five residents who were reviewed for vaccinations, with the potential to impact all 59 residents in the facility. For each of the five residents, there was no documentation in the medical records regarding the administration of influenza or pneumococcal vaccines, nor any record of consent, declination, or education provided about these vaccines. Specifically, the medical records for residents with various diagnoses, including dementia, schizophrenia, muscle weakness, congestive heart failure, asthma, morbid obesity, diabetes, respiratory failure, and COPD, lacked any evidence of vaccination status or related documentation. Interviews with the President of Operations and the Regional Registered Nurse confirmed that they were unable to locate any vaccination records, refusals, or educational materials for these residents in the electronic medical records. This absence of documentation was consistent across all five residents reviewed. Facility policies required that for residents who received vaccines, the date, lot number, expiration date, person administering, and site of vaccination be documented in the medical record, and that refusals also be documented. Additionally, policies stated that residents should be assessed for vaccine eligibility upon or prior to admission and offered the vaccine series within thirty days unless contraindicated. The CDC guidance reviewed also emphasized the importance of following recommended immunization schedules for at-risk populations, but there was no evidence that these requirements were met for the residents in question.