Failure to Document Staff Influenza Vaccination per Facility Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to implementation of its influenza vaccination policy for staff. An LVN reported in interview that they had received an influenza vaccine in August 2025 but had not provided proof of vaccination to the facility. Review of the LVN’s Personnel Action Form, dated with a hire date in early December 2025, and the employee file showed there was no documentation of influenza vaccination. The Director of Staffing Development confirmed that the facility’s practice was to obtain a copy of each employee’s influenza vaccination documentation and place it in the employee file, and acknowledged that this documentation was missing for the LVN. The DON stated it was important to have the LVN’s influenza vaccine documentation on file because it would indicate whether the LVN had received the vaccine and was important for resident safety. Review of the facility’s written P&P titled “Influenza Vaccine,” revised March 2022, showed that all employees without medical contraindications were to be offered the influenza vaccine annually, and that employees hired between October 1 and March 31 were to be offered the vaccine within five working days of job assignment. For those who received the vaccine, the policy required documentation of the vaccination details in the employee’s medical record, and stated that staff could obtain vaccines from personal physicians but must provide documentation of previous vaccination to the facility. The absence of any influenza vaccination record for the LVN in the employee file was inconsistent with these policy requirements.
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