Failure to Care Plan Vaccine Refusal and Influenza Diagnosis for Two Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans addressing vaccination refusal and influenza status for two residents. One resident was originally admitted with sepsis and a urinary tract infection and had documented capacity to understand and make decisions, with an MDS showing moderately impaired cognitive skills and a need for supervision or assistance with several ADLs. Vaccine consent forms dated shortly after admission showed this resident declined COVID-19, RSV, influenza, and pneumococcal vaccines. However, review of the resident’s care plan with the Infection Prevention Nurse (IP) revealed there was no care plan addressing the resident’s refusal of these vaccines, despite facility policy requiring a care plan when a resident declines vaccine administration upon admission. Another resident, admitted with a right femur fracture and hemiplegia/hemiparesis following cerebral infarction, also had documented capacity to understand and make decisions, but an MDS indicated severely impaired cognitive skills for daily decision making and dependence or high assistance needs for toileting, showering, dressing, hygiene, and eating. The IP reported being informed that this resident tested positive for influenza, yet concurrent review of the resident’s care plan showed there was no care plan addressing the resident’s influenza diagnosis. Both the IP and the DON acknowledged the absence of individualized care plans for these current medical conditions, despite a written policy requiring comprehensive, person-centered care plans with measurable objectives and timetables, including for services not provided due to a resident’s exercise of the right to refuse treatment.
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