Lack of Documentation for Flu and Pneumonia Vaccine Consents
Penalty
Summary
The facility failed to provide and document influenza and pneumococcal vaccinations according to accepted standards of practice. Specifically, the facility did not retain documentation that residents or their representatives received education regarding the vaccines, nor did it retain records indicating whether the vaccines were accepted or refused. This deficiency was identified through record review and staff interview, affecting three out of five residents reviewed for immunizations. The facility's policy required that residents or their representatives complete consent or declination forms for these vaccines, but these forms were missing from the medical records. For the residents involved, immunization reports indicated that some received the influenza vaccine while others refused the pneumococcal vaccine. However, there was no supporting documentation in their records to confirm that informed consent or refusal was obtained, or that education about the benefits and potential side effects was provided. The DON confirmed that the required immunization consents and refusals could not be located, attributing the issue to missing documentation from the prior Infection Preventionist.