Failure to Document Vaccine Education and Obtain Proper Consent for Influenza Vaccination
Penalty
Summary
The facility failed to properly document education regarding the influenza vaccine for one resident and failed to obtain a required signature on the influenza vaccine consent/refusal form for another resident. In the first instance, a resident who was cognitively intact consented to receive the influenza vaccine and signed the consent form, but there was no Vaccine Information Statement (VIS) attached, nor was there documentation in the electronic medical record (EMR) indicating that education about the vaccine was provided to the resident or their representative. The Infection Preventionist confirmed that she did not always bring a VIS form when discussing vaccination and that documentation of education was missing from the EMR. Both the Director of Nursing (DON) and the Administrator were unable to explain why the VIS was not provided or why education was not documented, despite facility policy requiring that the VIS be provided and education documented prior to vaccine administration. In the second case, another resident with moderate cognitive impairment had a consent form marked as consenting to the influenza vaccine, but neither the resident nor their representative had signed the form. The form was witnessed by two staff members, including the Infection Preventionist, who stated that she witnessed verbal consent but did not document this on the form. The vaccine was administered without a resident or representative signature, and the VIS form attached also lacked the required signature. The DON stated that the resident likely refused to sign but gave verbal consent, yet there was no documentation of verbal or telephone consent as required. Interviews with staff revealed inconsistent practices regarding the provision and documentation of vaccine education and consent. The Infection Preventionist, DON, and Administrator all acknowledged gaps in documentation and were unable to provide reasons for the missing information. Facility policy required that the VIS be provided and education documented prior to vaccine administration, but these steps were not consistently followed or recorded for the residents involved.