Failure to Obtain Consent and Provide Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to obtain consent and provide education prior to administering the influenza vaccine to three residents. For each of these residents, medical record review showed that the influenza vaccination was given, but there was no documentation of a signed consent form or evidence that vaccine information or education was provided before administration. Interviews with the MDS Coordinator confirmed that the required consent forms and educational documentation were missing for all three residents. The affected residents had complex medical histories, including diagnoses such as dementia, chronic kidney disease, cirrhosis, Alzheimer's disease, malnutrition, chronic obstructive pulmonary disease, and other serious conditions. Despite the facility's policy requiring that the CDC's vaccine information statement be provided and consent obtained prior to vaccination, these steps were not documented or completed for the residents in question.