Failure to Screen, Document, and Obtain Informed Consent for Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly screened and provided with informed consent for influenza and pneumococcal vaccinations. For five residents reviewed, there were multiple instances where either the risk and benefits of the vaccines were not documented, the required Vaccine Information Sheet (VIS) was not provided, or the vaccines were not offered or administered according to protocol. In several cases, consent for vaccination was obtained, but there was no documentation that the risks and benefits were reviewed with the resident or their representative. In one instance, a resident's refusal of the influenza vaccine was documented, but there was no evidence that the risks and benefits of refusal were discussed. Another resident had not been offered either the influenza or pneumococcal vaccine since admission, and their vaccination status had not been reviewed as part of the admission process. Staff interviews confirmed these deficiencies, with the Infection Preventionist and Director of Nursing Services acknowledging that the review of risks, benefits, and provision of VIS were not consistently documented or completed for every vaccine administration. The Director of Nursing Services also confirmed that it did not meet expectations for residents' vaccination status to go unreviewed or for vaccines not to be offered as required.