Failure to Document Offer of Pneumonia Vaccine
Penalty
Summary
The facility failed to ensure that a resident's medical record included documentation that they were offered the pneumonia vaccine, as required by facility policy. The policy specified that the pneumonia immunization should be offered at admission if there was no history of prior immunization, and that immunization should be administered unless medically contraindicated or refused by the resident or their legal representative. Review of the resident's records showed no indication that the pneumonia vaccine was offered or administered, and there was no documentation of consent or refusal. The resident in question had a history of dementia and chronic obstructive pulmonary disease and was assessed as having moderate cognitive impairment. Interviews with the Infection Preventionist (IP) and the Director of Nursing (DON) confirmed that the consent process for the pneumonia vaccine had not been completed for this resident. The IP stated that the consent form had been mailed out but was not returned, and the DON explained that the facility typically sent letters and educational materials to responsible parties to obtain consent. Despite these procedures, there was no documentation in the resident's record to show that the vaccine was offered or that consent or refusal was obtained.