Failure to Offer and Document Flu and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer, obtain informed consent, and provide education regarding influenza and pneumococcal vaccinations to two out of five sampled residents. One resident was not offered the flu vaccine for two consecutive years, and there was no documentation of a refusal or education provided to the resident or their responsible party. The resident's medical record did not contain a signed consent or refusal form for the flu vaccine during the relevant flu seasons, despite the facility's policy requiring annual offering and documentation. Another resident was not offered the pneumococcal vaccine within 30 days of admission, as required by facility policy. The resident, who was eligible for the vaccine and had a history of pneumonia requiring antibiotic treatment, had no record of being offered the vaccine, no consent form, and no documentation of education or refusal in the medical record. Interviews with facility staff confirmed that the vaccine should have been offered and documented, but there was no evidence this occurred. Facility policies for both influenza and pneumococcal vaccines require that residents be assessed for eligibility, offered the vaccines, and that informed consent or refusal be documented, along with education about the risks and benefits. In both cases, the required processes were not followed, and the necessary documentation was missing from the residents' medical records.