Incomplete Vaccine Consent and Education Documentation: The facility failed to consistently document vaccine eligibility screening and failed to show that residents or responsible parties received flu and pneumococcal education materials before consent. Records for three residents showed blank or incomplete screening sections, missing dates, missing staff signatures, and no clear evidence of signed acknowledgment that vaccine fact sheets or education on risks and benefits were provided before administration.
Failure to Offer Pneumococcal Vaccine: A resident with DM, dementia, and severely impaired cognition had prior pneumococcal immunizations documented, but the chart lacked evidence that PCV20 was offered on admission or afterward. The IP RN stated the resident was eligible for the vaccine but was marked ineligible because consent from the responsible party was not obtained, and she had not tried again to obtain consent even though she had contacted the responsible party about other vaccines.
Two residents with significant chronic conditions and impaired cognition were not kept current on pneumococcal vaccination. One resident had a pneumococcal vaccine documented only after a long delay, while the other had no pneumococcal vaccine identified in the record. Staff reported fragmented vaccine documentation, missing logs from prior ownership, and delays related to outbreaks and staffing changes.
Missing Documentation of Influenza Vaccine Education: The facility failed to document education provided before influenza vaccination for 3 residents. One resident was cognitively intact with MS, one had epilepsy and muscle weakness with a responsible party involved, and one had dementia with moderate cognitive impairment and a conservator. All had consent on file and received the flu vaccine, but the EMR/immunization records did not show what education was provided about the vaccine, despite staff stating education was given and the policy requiring documentation of education and the CDC VIS.
A resident with CKD, DM2, and COPD was admitted cognitively intact, but the facility failed to document that influenza and pneumococcal vaccines were offered or that prior immunization status was assessed on admission. The IP nurse could not produce vaccine records or consent documentation and stated the consent review and vaccine history check were not completed as required by policy.
Failure to Offer and Document Vaccination Consent/Declination: A resident with intact cognition and another resident with chronic pain, arthritis, and insomnia had pneumococcal vaccine history documented, but the chart did not show they were offered the vaccine on admission, which pneumococcal product was given, or that consent or declination was obtained. A third resident with progressive lung disease, lung cancer, and HTN also lacked documentation that pneumococcal and influenza vaccines were offered or declined on admission. The IP RN stated she was responsible for ensuring residents were offered these vaccines on admission.
Failure to review and administer pneumococcal vaccines for two residents. One resident with HTN, dementia, and depression signed consent for PCV20, but the EMR showed no historical pneumococcal vaccines and no pending order. Another resident's admission vaccination form was left blank, showing vaccination status was not reviewed and the vaccine was not offered. An LPN/IP stated she had not completed pneumococcal vaccine review or administration due to outbreak-related time constraints, despite knowing the facility policy.
Failure to Assess and Document Pneumococcal Vaccinations A facility failed to ensure pneumococcal vaccination status was assessed, offered, and documented for multiple residents. Several residents with significant medical conditions and impaired cognition had consents on file, but the record did not show the vaccine was administered, refused, contraindicated, or otherwise tracked. An LPN/IP and the DON/ADNS acknowledged problems with admission paperwork, missing vaccine forms, and no tracking system for vaccination status.
Failure to Offer Pneumococcal Vaccine on Admission: A resident with anxiety, dementia, and HTN was admitted with documented prior pneumococcal immunizations, but the clinical and consent records did not show that the pneumococcal vaccine was offered on admission. The IP RN stated she was responsible for ensuring residents are offered the vaccine, but she did not offer it because she believed the resident had already completed the series and did not discuss vaccine appropriateness with the provider.
Failure to document and track flu and pneumococcal vaccinations affected 4 of 5 residents reviewed. One resident had pneumococcal vaccine administration documented without a signed consent, another had no record that influenza vaccine was offered, and two residents had consent documented but no record that the vaccines were actually administered. The IP stated she relied only on clinical records and had no tracking system for resident vaccination status.
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