Failure to Obtain Documented Consent Prior to Influenza Vaccination
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document consent prior to administering an influenza vaccination. Record review showed that Resident #80 was admitted on an unspecified date and received an influenza vaccine on 9/22/25, as documented on the September 2025 Medication Administration Record. However, the only immunization consent form in Resident #80’s medical record, dated 11/20/25, had the influenza vaccination option left blank and did not contain the resident’s signature consenting to the flu vaccine. During an interview on 1/8/26 at 10:18 AM, the Director of Nursing confirmed there was no consent on file for the flu vaccination given on 9/22/25 and stated that consents should always be obtained before vaccine administration and maintained in the resident’s medical record. This lack of documented consent prior to vaccination for Resident #80, as confirmed by both record review and staff interview, constitutes the identified deficiency.
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.