Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its policies for offering and documenting influenza and pneumococcal vaccinations for two residents. For one resident, admitted on an unspecified date, review of the EMR under the Immunization tab on 03/30/26 showed no documentation that the influenza vaccine had been offered or declined, and there was no record of prior influenza vaccination or a physician-documented contraindication. The facility was unable to provide any declination form for this resident’s annual influenza vaccination. For another resident, also admitted on an unspecified date, the EMR Immunization tab on 03/30/26 lacked documentation that either the influenza vaccine or the PCV20 pneumococcal vaccine had been offered or declined, and there was no record of historical administration or physician-documented contraindications for either vaccine. The facility could not produce declination forms for this resident’s annual influenza or PCV20 vaccinations. During interviews, a licensed nurse stated she was not responsible for tracking resident immunization history or vaccine administration, and an administrative nurse reported she could not locate the consent or declination forms and indicated the infection preventionist was responsible for tracking and documenting immunizations. The facility’s written policies stated that all residents without medical contraindications would be offered influenza and pneumococcal vaccines and that pertinent information about vaccine risks and benefits would be provided to residents or their legal representatives.
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