Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that the pneumococcal and influenza vaccines were offered to a resident, as required by policy and regulation. Review of the resident's immunization record showed that the resident had received an influenza vaccine in the previous year and a pneumococcal vaccine dose several years prior, but there was no documentation that the annual influenza vaccine or the most current pneumococcal vaccine was offered or administered. Additionally, there was no evidence in the electronic health record that the resident was informed about the risks and benefits of these vaccines or that any refusal was documented. Interviews with facility staff, including the Infection Preventionist, RN Unit Manager, Consultant Pharmacist, and Director of Nursing, revealed inconsistent practices and a lack of documentation regarding vaccine offers, administration, and consent. Staff were unable to locate records of vaccine offers, refusals, or administration for the resident in question, and the state immunization database indicated the resident was past due for both vaccines. The facility's policies required that vaccines be offered and documented, but these procedures were not followed for the resident reviewed.