Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to ensure that Resident #64 was offered the influenza vaccine during the period from 02/27/25 to 03/31/25. Record review showed that Resident #64, who was admitted with diagnoses including altered mental status, muscle weakness, cognitive communication deficit, and major depressive disorder, had intact cognition according to the Minimum Data Set assessment. Despite facility policy requiring annual offering of the flu vaccine and documentation of consent or refusal in the medical record, there was no evidence in the resident's medical record that the vaccine was offered, nor was there documentation of consent or refusal. During an interview, the Regional Director of Clinical Services confirmed that no information regarding the resident's consent or refusal for the influenza immunization could be located.