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 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.
A resident with a history of receiving Pneumovax (PPSV23) did not have documentation of being offered a pneumococcal conjugate vaccine as recommended by CDC guidelines. Facility policy required nursing staff to screen, educate, and document immunization status, but this process was not followed for the resident, as confirmed by staff and record review.
A resident who was cognitively intact had previously received PCV13 and PPSV23 vaccines, but there was no documentation that the resident was educated about, offered, or provided the opportunity to consent to or refuse the recommended PCV20 or PVC21 vaccination, as required by CDC guidelines and facility policy.
Several residents with chronic conditions were not offered the pneumococcal vaccine as required by CDC guidelines and facility policy. The DON confirmed that eligible residents had not been assessed or offered the vaccine, and documentation was lacking or inconsistent across records. Some residents had received earlier vaccines but were not offered updated versions, and staff interviews confirmed the deficiency.
Staff administered influenza vaccines to several residents without obtaining signed consent or providing required education about the vaccine's benefits and side effects. Medical records lacked documentation of consent and education, despite facility policy requiring these steps before vaccination. Leadership acknowledged the process was not consistently followed.
Two residents with severe cognitive impairment and multiple medical conditions were not offered or documented as having received the annual influenza vaccine, despite facility policy and documented consent. The DON was unable to explain the oversight during staff interview.
Three residents, including individuals with respiratory failure, lung cancer, COPD, and cognitive impairment, were not offered or administered the appropriate pneumococcal vaccines as required by CDC guidelines. In each case, either consent was obtained but the vaccine was not given, or the opportunity to consent or refuse was not provided when residents became eligible. The DON reported a lack of knowledge regarding the vaccine schedule and had not proactively identified residents due for immunization.
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