Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to maintain a system for documenting that residents were provided education regarding the benefits and potential side effects of pneumococcal and influenza vaccines, as well as documentation of consent or refusal for immunization. In the case reviewed, a resident was admitted and subsequently declined both the influenza and pneumococcal vaccines. However, the medical record did not contain evidence that the resident was educated on the benefits and risks of these vaccines, nor was there a copy of the consent or declination form maintained in the record. Interviews with the interim DON and ADON confirmed that no further documentation was available to support that the required education or consent/refusal process had occurred. Review of the facility's policies for both influenza and pneumococcal vaccines indicated that education and documentation of consent or refusal should be provided and maintained in the resident's medical record, but this was not followed in the instance reviewed.