Failure to Document Influenza Vaccine Education and Consent
Penalty
Summary
The facility failed to ensure that a resident's medical record included required documentation regarding influenza vaccination. Specifically, the record did not indicate that the resident or their representative was provided education about the benefits and potential side effects of the influenza immunization, nor did it document whether the resident received the vaccine, declined it, or had a medical contraindication. The facility's policy requires that all residents be offered the influenza vaccine annually and that any refusal be documented and placed in the resident's medical record. In this instance, a resident was admitted to the facility and had documentation of receiving the influenza vaccine in a previous season, but there was no record of vaccination or declination for the most recent influenza season. When surveyors requested documentation, the facility was unable to provide a signed and dated declination form until after the request was made, at which point the resident and staff completed the form. This indicates that the required documentation was not present in the medical record at the time of the surveyor's initial review.