Delayed and Incomplete Vaccine Administration and Consent Documentation
Penalty
Summary
Surveyors identified deficiencies in the facility's administration of influenza, pneumococcal, and COVID-19 vaccinations for residents. In four out of five clinical records reviewed, staff failed to provide vaccines in a timely manner after consent was obtained and did not consistently follow up with responsible parties to secure consent or declination. For one resident, the consent form was incomplete, lacking a signature or date, and although the family was noted as deciding, there was no documentation of follow-up attempts after the initial entry. Another resident's family provided verbal consent for vaccinations, but the vaccines were not administered until over two months later, with no documented reason for the delay. In a third case, the consent form indicated the resident was conserved and awaiting family decision, but there was no date or documentation of follow-up efforts. For a fourth resident, vaccines were administered 17 days after consent was given, again with no explanation for the delay. Facility policies for influenza, pneumococcal, and COVID-19 vaccines require timely offering and administration of vaccines, documentation of refusals, and re-offering as appropriate, in accordance with CDC guidelines. However, staff interviews and record reviews revealed lapses in following these policies, including lack of documentation for family communications, delays in vaccine administration after consent, and incomplete consent forms. These actions and omissions resulted in noncompliance with the facility's own infection control and immunization protocols.