Failure to document pneumococcal vaccine screening, education, and consent for 3 residents. Residents with intact cognition had prior pneumococcal immunizations on record, but the chart lacked documentation that they were educated about, offered, or consented to or refused PCV20 or PCV21. The IP stated the facility relied on physicians to track vaccine due dates and had no internal process for managing these immunizations.
Failure to document vaccine education and consent. The facility did not provide documented education or obtain informed consent for influenza vaccination for four residents and pneumococcal vaccination for three residents. Review of EHRs showed several residents had not received the indicated vaccines, and the DON could not find records showing education was provided or signed refusals were obtained. The Infection Control Manual required education, consent, and EHR documentation for immunizations.
Failure to administer ordered vaccinations: one resident with intact cognition and diagnoses including Parkinsonism, HTN, and respiratory failure did not receive the annual flu vaccine despite a physician order and signed consent, with no order entered in the EHR and no documentation of administration. Another resident with severe cognitive impairment and diagnoses including a hip fracture and dementia did not receive the pneumococcal vaccine despite a physician order and signed consent, and the EHR also lacked an order and administration record. The DON stated the residents had consented but the facility had not given the vaccines yet.
Failure to screen residents for pneumococcal vaccine eligibility was cited after two residents had incomplete immunization documentation. One resident had severely impaired cognition and records showed influenza and COVID vaccines but no pneumococcal vaccine documentation, while another resident with dementia and diabetes had MDS documentation stating pneumococcal vaccination was up to date despite the immunization form showing only COVID and influenza vaccines; pharmacy documentation indicated the resident qualified for Prevnar 20. The DON stated vaccination history should be entered into the EHR within 48 hours of admission and that both residents should have been offered the pneumococcal vaccine, with declination and education documented if refused.
Failure to offer updated pneumococcal vaccinations for 4 of 5 residents reviewed. Records showed prior PCV13 and/or PPSV23 immunizations, but the facility’s consent forms only addressed whether Pneumovax should be given when no prior vaccine history was found and did not include current CDC guidance or education about newer options such as PCV20 or PCV21. The DON stated the facility worked with the pharmacy for vaccine clinics and expected residents to be up to date, but additional vaccine records could not be located.
Failure to complete updated pneumococcal vaccination for a resident with consent and a care plan directing immunizations. The resident had intact cognition, later experienced hospitalization with pneumonia and acute hypoxic respiratory failure, and the MDS listed pneumococcal status as up to date even though the EHR showed the vaccine pending. Review of notes, EMARs, and orders found no documentation of contraindications, a hold order, administration of the vaccine, or a reason it was not given; staff reported the screening was done but follow-through did not occur.
Missing Documentation for Flu and Pneumonia Vaccinations: The facility failed to ensure several residents were offered or received flu and/or pneumonia vaccines, and the clinical records lacked documentation of those offers or administrations. The DON stated the vaccine provider conducted vaccine clinics but did not provide the facility a list of residents who received the vaccines, leaving records incomplete for multiple residents.
Failure to offer and/or administer influenza vaccine to two residents. One resident had moderately impaired cognition, prior flu vaccinations, and documented POA consent for flu, COVID, and RSV vaccines, but the facility could not provide documentation of a later refusal after consent. Another resident had a BIMS score of 11/15, prior flu vaccinations, and no flu vaccine during the current season; the chart lacked documentation explaining why the vaccine was not offered or given. The DON and IP/ADON stated vaccinations were completed in the fall and consent would be obtained and documented before administration.
Failure to administer a pneumococcal vaccine after consent was obtained. A resident with cancer, sepsis, respiratory failure, and a hx of pneumonia was admitted with immunization status listed as not up-to-date and vaccine past due. The EHR showed consent for Prevnar 20, but the record lacked documentation of prior PPSV23 or other pneumococcal conjugate vaccines, and progress notes did not show the vaccine was given. The ADON/IP stated the order was entered but not marked yes and was on the MAR but not administered.
Failure to provide consented pneumococcal vaccinations for two residents was identified. Both residents had BIMS scores of 15, indicating intact cognition, and both had signed consent forms showing agreement to receive the vaccine, but the EHR lacked documentation that the vaccine was administered. The MDS noted the vaccines were not received because the facility was not offering them, and the interim DON confirmed neither resident got the pneumococcal vaccine as consented.
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