Failure to Educate Residents on Risks and Benefits of Flu and Pneumonia Vaccines
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to educate residents on the risks and benefits of pneumococcal and influenza immunizations as required by facility policy and SOM Appendix PP. The facility’s written policy, last reviewed on 12/22/25, stated that prior to administration of influenza or pneumococcal vaccines, the resident or legal representative would be provided the current CDC Vaccine Information Statement, supplemented with visual or oral explanations, and that a signed consent form and documentation of education and acceptance/refusal would be maintained in the medical record. Record review and staff interview showed that this process was not followed for several residents. For one resident with muscle wasting and osteonecrosis who was readmitted to the facility, the medical record did not contain documentation that he was offered the opportunity to accept or decline the pneumococcal vaccine based on education about risks and benefits, and the Clinical RN confirmed there were no records of such education. For another resident with cancer and coronary artery disease, the record likewise lacked documentation of education or an opportunity to accept or decline the pneumococcal vaccine, which the Clinical RN also confirmed. A third resident with osteoarthritis, protein-calorie malnutrition, and dementia, and/or her representative, had no documented evidence in the record that she was offered the opportunity to accept or decline influenza and pneumococcal vaccines based on staff education regarding risks and benefits, and the Clinical RN again stated there were no records of this education. This lack of documented education and consent occurred for 3 of 5 residents reviewed for current immunizations.
