Failure to Document Vaccine Education and Consent
Penalty
Summary
The facility failed to properly document education regarding the benefits and potential side effects of influenza and pneumococcal vaccines, as well as the acceptance or declination of these vaccines, in the medical records of three out of five residents reviewed. For one resident who was severely cognitively impaired, the family refused both vaccines, but there was no documentation that education was provided to the family, and the consent form was incomplete, lacking a signature, date, and the name of the family member who declined. Another resident, who was moderately cognitively impaired, had a consent form indicating both vaccines were declined, but the form was missing a signature, date, and family member identification. This resident also reported not being offered the vaccines, despite the record indicating a declination. A third resident, who was cognitively intact, had no documentation in the medical record regarding education about the vaccines or a record of consent or declination. The Infection Preventionist stated that she would write 'verbal' on the consent form after speaking with residents, but not all forms were signed or dated, and some residents' records lacked any documentation of vaccine education or decision. The DON and Administrator both acknowledged that all residents should be offered the vaccines and that proper documentation should be maintained, but these requirements were not met for the residents reviewed.