Failure to Obtain and Document Consent and Education Prior to Influenza Vaccination
Penalty
Summary
The facility failed to follow its policy requiring education and signed consent prior to administering influenza and pneumonia vaccinations. The written policy titled “Pneumonia/Influenza Vaccinations” directed staff to contact the resident and family to explain the importance of vaccinations and to obtain signed consent from the resident and/or family. For one resident, admitted with chronic kidney disease stage 5, end stage renal disease, pneumonia, schizophrenia, and bipolar disorder, the record identified a health care proxy as the responsible party and a care plan focus of refusing vaccines due to allergy to some components, with an intervention to assess for consent or refusal upon admission and periodically with the resident and responsible party. The resident’s MDS showed a BIMS score of 3, indicating severely impaired cognition. Despite these requirements and the resident’s cognitive status and care plan, the physician’s order for a high-dose influenza vaccine was implemented and the vaccine was administered on a documented date and time without any documented evidence of prior education, consent, or refusal from the resident or health care proxy. The eMAR confirmed the vaccine was given, while the medical record lacked a signed consent form or documentation of education about risks and benefits before administration. A subsequent influenza vaccination request and consent form, signed by the responsible party several days after the vaccine was given, documented a refusal of the influenza vaccine on an ongoing basis. Staff interviews confirmed that an LPN administered the vaccine based on a list of residents purported to have consented, without personally verifying a signed consent, and the infection control nurse and ADON acknowledged that consent/refusal and education should have been obtained and documented before the vaccine was administered, but this did not occur for this resident.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.