Failure to Document Flu and Pneumonia Vaccine Consents, Declinations, and Education
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of influenza and pneumococcal vaccination consents or declinations, as well as failure to document education on the benefits and potential side effects of these vaccines, for all five residents reviewed. For a cognitively intact resident admitted on a specified date, the MDS showed she was not offered the influenza vaccine and had declined the pneumococcal vaccine, but her medical record did not contain the date of declination, any documentation of an influenza vaccine for the current season, or any record that the vaccines were offered, accepted, or declined, or that education was provided. During interview, this resident could not recall whether she had been offered either vaccine, and the facility could not produce supporting documentation. For a severely cognitively impaired resident, the MDS indicated the resident was not offered influenza or pneumococcal vaccines, while the medical record stated the resident declined both vaccines without including dates of declination. The facility was unable to provide documentation that either vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education on benefits and potential side effects was provided. Another severely cognitively impaired resident had no documentation in the medical record for either influenza or pneumococcal vaccination, and the MDS also indicated the resident was not offered these vaccines. The facility again could not provide evidence that the vaccines were offered, that a decision was made by the resident or responsible party, or that any vaccine education occurred. A further severely cognitively impaired resident had documentation that a pneumococcal vaccine and a prior season influenza vaccine were administered outside the facility, but there was no documentation of an influenza vaccine for the current season. The MDS indicated this resident was not offered the influenza vaccine, and the facility could not provide documentation that the current season influenza vaccine was offered, that the resident or responsible party had the opportunity to accept or decline, or that education was provided. Another resident with moderate cognitive impairment had no documentation in the medical record for either influenza or pneumococcal vaccines, and the MDS indicated these vaccines were not offered. Interviews with the current DON, the previous DON, and the Administrator revealed that the current DON had not yet started gathering immunization information, the previous DON had not received guidance on resident immunizations and did not know if they were being done, and the Administrator was unaware that immunizations had not been completed or offered, despite expecting that residents would receive education and consent per protocol.
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