Failure to Document Influenza Vaccination Offer and Declination
Penalty
Summary
The deficiency involves the facility’s failure to follow its influenza vaccination policy by not properly documenting the offer, consent, declination, or contraindication for an influenza vaccine for Resident 28. The facility had a census of 40 residents, with a sample of 12 residents and 5 reviewed for immunization status. Record review of Resident 28’s EMR under the Immunization tab showed no documentation that the influenza vaccine was offered or declined, and no record of a historical influenza vaccination or a physician-documented contraindication, despite the resident’s admission earlier in the month. Although the facility later provided a declination form for the annual influenza vaccination dated the day after the record review, this documentation was not present at the time of the initial review. During an interview, the Infection Preventionist, who was responsible for tracking immunizations, stated she had left a message with the resident’s legal representative regarding immunizations and reported that the legal representative had declined the influenza vaccination, but this declination was not documented in the EMR as required by facility policy. The facility’s written Influenza Vaccination policy stated that it was the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering annual influenza immunization to residents, staff, and volunteers, but the required documentation of this process was not completed for Resident 28.
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