Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to properly educate and offer pneumococcal and influenza immunizations to residents upon admission, as well as to maintain accurate documentation of immunization status and refusals. For one resident with severely impaired cognition, there was no evidence in the medical record that either the pneumococcal or influenza vaccines were offered, administered, or refused, nor was there any signed consent or refusal form present. The Assistant Director of Nursing (ADON) confirmed the absence of immunization records and was unable to explain how this oversight occurred. For another resident with moderately impaired cognition, although the pneumococcal vaccine was reportedly offered and declined, the medical record lacked a signed refusal form and any documentation of education provided regarding the risks and benefits of refusing the vaccine. The ADON acknowledged the missing documentation and was unable to provide further information during the survey. The Administrator confirmed that immunizations should be discussed and documented on admission, but this process was not followed for the residents in question.