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F0550
G

Resident Rights Violated When Nurse Administers Unwanted Second Influenza Vaccine

Toledo, Ohio Survey Completed on 12-01-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A facility failed to honor a resident's right to self-determination and a dignified existence when a nurse administered a second dose of the influenza vaccine to a resident against her will. The resident, who had a history of abuse and PTSD, had previously declined the influenza and pneumococcal vaccinations upon admission, with her declination witnessed and documented. Despite this, the resident later consented to and received the influenza vaccine in October. In November, a physician order was placed for a pneumococcal vaccine, but the vaccine was not yet available in the facility. On the day of the incident, a registered nurse approached the resident to administer what was supposed to be the pneumococcal vaccine. The resident verbally refused the vaccination, stating she had already received the influenza vaccine, and her husband, present via video call, also expressed concern. The nurse dismissed their objections, insisted they did not know what they were talking about, and proceeded to inject the resident with the influenza vaccine a second time, despite her clear refusal and previous administration. This action was documented as a medication error, as the nurse administered the wrong vaccine and did so without the resident's consent. The resident reported feeling afraid of the nurse following the incident and expressed concerns about her health due to receiving two influenza vaccinations within a short period. The facility's policies confirmed residents' rights to refuse immunizations and required medications to be administered as ordered and in accordance with professional standards. The administrator verified that the nurse administered the influenza vaccine against the resident's will and that a medication error had occurred.

An unhandled error has occurred. Reload 🗙