Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that required immunizations for influenza and pneumococcal disease were offered and documented for certain residents, as identified through policy review, clinical record review, and staff interview. Specifically, one resident with diagnoses including dementia, high blood pressure, and hyperlipidemia was not offered the influenza vaccine during the current vaccination season, with documentation indicating the vaccine was not offered and no record of administration or refusal. Additionally, two residents with medical histories including high blood pressure, depression, anxiety, hemiplegia, and a history of falls did not have documentation in their clinical records that the pneumococcal vaccine was offered, administered, or declined. The facility's vaccination policy required that influenza, pneumococcal, and COVID vaccines be administered per orders, with consents, refusals, or medical ineligibility documented in the electronic health record. However, review of the Minimum Data Set (MDS) and clinical records for the affected residents showed missing documentation regarding the offering and administration or refusal of these vaccines. The Infection Preventionist confirmed that the facility did not ensure the required immunizations were offered as mandated.