Failure to Offer and Document Flu and Pneumonia Vaccinations and Education
Penalty
Summary
The facility failed to ensure that influenza and pneumococcal immunizations were offered and that education on the risks and benefits of these immunizations was provided to two out of five residents reviewed for immunization and infection control. For one resident with a history of stroke, immunodeficiency, and anxiety, the medical record showed no evidence that either immunization was offered or that any education regarding the risks and benefits was provided. The resident also did not recall any discussion about immunizations. For another resident with diagnoses including urinary tract infection, malnutrition, and repeated falls, there was no documentation that a pneumococcal immunization was offered or that education on risks and benefits was provided to the resident or their representative. Interviews with staff, including the Infection Control Nurse and the Director of Nursing Services, confirmed that the process was to review immunizations upon admission, offer them, provide education, and document consent or declination. However, in these two cases, there was no documentation in the medical records to support that these steps were completed. Both residents did not recall any previous conversations regarding immunizations, and staff acknowledged the lack of documentation.