Failure to Administer Influenza Vaccine After Resident Consent
Penalty
Summary
The facility failed to provide an influenza vaccination to one resident who had consented to receive it. The resident was admitted on 11/04/25 with multiple significant diagnoses, including spondylosis, critical illness myopathy, severe protein calorie malnutrition, monoclonal gammopathy, dependence on renal dialysis, osteophyte, acute on chronic systolic heart failure, major depressive disorder, Alzheimer's disease, muscle wasting and atrophy, pleural effusion, candidal stomatitis, atrioventricular block, paroxysmal atrial fibrillation, and chronic systolic heart failure. The resident’s Minimum Data Set documented a Brief Interview for Mental Status score of 12, indicating moderately impaired cognition. On 11/05/25, the resident’s Vaccine Informed Consent Form documented that the resident accepted the influenza vaccine, with “yes” marked for receiving the influenza vaccination. Despite this documented consent, the Immunization Report showed the most recent influenza vaccination for the resident was dated 12/19/2022, prior to the current admission, and there was no record of an influenza vaccine being administered during the current stay. During an interview on 12/04/25 at 11:31 AM, the Director of Nursing confirmed that the resident had not received an influenza vaccination while at the facility and stated she did not know why it had not been given. This failure occurred despite the facility’s written policy, dated 09/2015, which states that current and newly admitted residents will be offered the influenza vaccine from October through the end of March each year, in accordance with recommendations from CDC and other professional organizations.
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