Failure to Offer and Document Influenza and Pneumococcal Vaccinations per Policy
Penalty
Summary
The facility failed to follow its own policies and CDC guidelines regarding the offering and administration of influenza and pneumococcal vaccines to residents. Specifically, documentation was lacking to show that several residents or their representatives were provided education and offered these vaccines as required. For example, one resident with multiple diagnoses, including dementia and heart disease, had no documentation of being offered or educated about either the influenza or pneumococcal vaccine during the relevant period. Another resident with chronic respiratory conditions had consent for the pneumococcal vaccine documented, but the vaccine was not administered as of the survey date. Additionally, a resident with a history of atherosclerosis and dementia had documentation of a prior pneumococcal vaccine but no evidence of being offered or educated about additional pneumococcal vaccination or the influenza vaccine for the current season. Another resident with multiple chronic conditions, including diabetes and COPD, also lacked documentation of being offered or educated about the pneumococcal vaccine. In each case, the required education, offer, and documentation steps outlined in facility policy and CDC guidance were not followed. Interviews with facility staff confirmed that responsibility for immunizations had recently changed hands, and both the educator and DON acknowledged that residents should have been educated and offered vaccines per policy. The facility's written policies require assessment, education, offer, and documentation of vaccine status and resident decisions, but these steps were not consistently completed or recorded for the affected residents.