Failure to Administer Flu and Pneumonia Vaccines After Resident Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide pneumococcal and influenza vaccinations to a resident who had consented to receive them. Resident #4, admitted on an unspecified date, had a comprehensive MDS assessment indicating moderate cognitive impairment and showing that influenza and pneumococcal vaccines had not been offered. The medical record contained no documentation of vaccine administration or any consent forms indicating acceptance or refusal of these vaccinations. However, the Infection Preventionist (IP) later produced a pneumococcal and influenza vaccination consent form signed by Resident #4, dated 11/21/25, in which he consented to receiving both vaccinations. In an interview, Resident #4 recalled signing the consent form upon admission and confirmed that he wanted to receive the vaccinations. Multiple staff interviews revealed inconsistent and unclear processes for obtaining, communicating, and acting on vaccination consents, particularly for residents admitted between the facility’s twice-yearly vaccination clinics. The IP stated she was not involved in obtaining consents, administering, or tracking vaccinations beyond receiving lists from the Nurse Practitioner (NP) after clinics, and she was unsure how residents admitted between clinics were offered or administered vaccines. The DON acknowledged there was no established process to ensure such residents received vaccinations if desired and attributed Resident #4’s missed vaccinations to a communication breakdown. The Admissions Coordinator reported obtaining and uploading consents at admission but did not notify the NP or nursing staff when consents were signed and could not explain why Resident #4’s consent was missing from the medical record. The NP indicated she relied on nursing staff to provide consents before clinics and received only inconsistent notifications about new consents between clinics, and she confirmed there was no system to ensure residents admitted between clinics received vaccinations after consenting. The Administrator’s description of the expected notification process conflicted with staff reports, further demonstrating the lack of a functioning process that led to Resident #4 not receiving the consented vaccinations.
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