Failure to Obtain Immunization Consent for Resident Lacking Decision-Making Capacity
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control policy and procedures related to immunization consent for one resident. Resident 4 was admitted with diagnoses including benign neoplasm of the meninges, altered mental status, and adult failure to thrive. A history and physical dated 6/17/2025 documented that the resident did not have the capacity to understand and make decisions, and a Minimum Data Set dated 12/24/2025 indicated severe cognitive impairment. The same MDS showed the resident mostly required supervision or touching assistance for ADLs such as oral hygiene, toileting hygiene, showering/bathing, lower body dressing, personal hygiene, and putting on/taking off footwear. During an interview, the Infection Prevention Nurse stated that before administering vaccinations such as influenza, COVID, or pneumonia, a resident or their representative must sign a consent form to indicate they have been educated on the benefits and risks. The IPN confirmed there was no documented evidence that the resident’s representative had been given the consent. Review of the facility’s Infection Prevention and Control Program policy, last reviewed on 12/18/2025, showed that the program included immunization policies and procedures, including obtaining direct and proxy consent and specifying how often this should occur. The lack of documented consent for influenza, pneumonia, and COVID vaccinations for Resident 4, who lacked decision-making capacity, constituted a failure to follow the facility’s infection control policies and procedures.
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