Failure to Document Vaccine Education for Pneumococcal Immunization
Penalty
Summary
The facility failed to provide required education to a resident or the resident's representative regarding the benefits and potential side effects of the pneumococcal immunization. According to the facility's policy, all residents must be offered the pneumococcal vaccine and have the right to refuse, with documentation of both the offer and any refusal, including education provided. A review of the clinical record for one resident showed that the pneumococcal vaccine was refused, but there was no documented evidence that education about the vaccine's benefits and side effects was given to the resident or their representative. This was confirmed by the Infection Preventionist during an interview, who acknowledged the lack of documentation in the resident's medical record.