Failure to Document Vaccine Refusals in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented electronic health records for four out of five residents reviewed. Specifically, for multiple residents with various diagnoses including heart failure, peripheral vascular disease, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease, coronary artery disease, and respiratory failure, the electronic health record immunization section indicated that these residents refused vaccines such as the Covid-19, influenza, and pneumococcal vaccines. However, there were no corresponding entries in the progress notes documenting these refusals, as required by facility policy. Interviews with the DON revealed that declination forms were not obtained when residents refused vaccines, and documentation was only made if a vaccine was accepted. The DON stated that for residents with lower cognitive scores or a medical POA, the POA would be contacted, and refusals by POA would be documented in the progress notes. The Administrator confirmed that refusals should be charted in the medical record with a signed declination form. Facility policy also required that vaccine refusals be documented in the resident's medical record, which was not done in these cases.