Failure to Screen for Contraindications Prior to Influenza Vaccination
Penalty
Summary
The facility failed to assess two residents for medical contraindications prior to administering the Influenza vaccine, as required by its own policy. The policy specified that each resident should be assessed for possible contraindications before receiving the vaccine, and that findings should be documented in the medical record. For both residents, there was no evidence in the medical record that screening for contraindications was completed prior to vaccine administration, despite the existence of a Universal Vaccine Informed Consent/Declination Form designed to capture this information. The Infection Preventionist (IP) and Director of Nursing (DON) both confirmed that the required screening and documentation did not occur for these residents. The residents involved had significant medical histories, including conditions such as polyneuropathy, emphysema, severe protein-calorie malnutrition, adult failure to thrive, acute respiratory failure with hypoxia, metabolic encephalopathy, chronic kidney disease, dementia, and chronic respiratory failure with hypoxia. In both cases, consent for vaccination was obtained from the residents' emergency contacts, and the vaccines were administered without documented adverse reactions. However, the lack of documented screening for contraindications prior to administration constituted a failure to follow established procedures.