Failure to Document and Offer Required Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal and influenza immunizations were properly offered and/or provided to a resident, as required by facility policy and state regulations. Specifically, for one resident with a diagnosis including multiple sclerosis, the clinical record contained informed consent forms for both pneumococcal and influenza vaccines that did not indicate whether the resident accepted or declined the vaccines. There was no documentation to show that the facility identified these incomplete forms or made further attempts to determine the resident's immunization preferences. Additionally, there was no evidence in the clinical record that the vaccines were administered, declined, previously received, or medically contraindicated for this resident. The regional nurse consultant confirmed that the facility did not offer or provide the required vaccinations in accordance with established policies. This deficiency was identified through a review of facility policies, clinical records, and staff interviews.