cms_GU: 80
Data source: Big Local News · About: big-local-datasette
| rowid | facility_name | facility_id | address | city | state | zip | inspection_date | deficiency_tag | scope_severity | complaint | standard | eventid | inspection_text | filedate |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 80 | GUAM MEMORIAL HOSPITAL AUTHORITY | 655000 | 499 NORTH SABANA DRIVE | BARRIGADA | GU | 96913 | 2012-01-26 | 334 | E | 0 | 1 | J2NN11 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not develop policies and procedures that ensured that before offering influenza and/or pneumococcal immunizations, each resident or the resident's legal representative received education regarding the benefits and potential side effects of the immunization; that each resident was offered an influenza immunization October 1 through March 31 annually, unless the immunization was medically contraindicated or the resident had already been immunized during this time period; and that the resident's medical record included documentation that indicated, at a minimum, that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza or pneumococcal immunization. Findings include: 1. Resident 1 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. Review of the minimum data set ((MDS) dated [DATE] revealed that the resident was alert and oriented, and dependent on staff for most activities of daily living. Further review of the MDS revealed that Resident 1 did not receive the influenza vaccine at the facility for this year's influenza season and that it was offered but that the resident had declined. In addition, the MDS noted that the resident's pneumococcal vaccine was not up to date and that it was also offered but that the resident had also declined. During an interview on 1/25/12, Resident 1 stated that he had been informed about the influenza and pneumococcal vaccines but that he declined because he had heard of problems associated with them. When asked to give examples of problems he had previously heard, the resident was unable to state any. When asked if he was given any informational handouts about the influenza (for 2011 - 2012) and pneumococcal vaccines, Resident 1 was unable to respond. In a separate interview on 1/25/12, a licensed nursing staff stated that residents were screened for influenza and pneumococcal vaccinations within one week after admission, and that informational What you need to know handouts were provided to the each resident to educate them about the risk and benefits of both vaccines. The staff added that the vaccines were then given only after the resident had given consent. In the same interview on 1/25/12, Resident 1 was shown copies of handouts for both the influenza and pneumococcal vaccines. When asked if he was familiar with them, the resident responded that he had not seen the handouts before. After reading the the copies, Resident 1 stated that it would have been a good idea to receive the influenza vaccine at least. Review of Resident 1's medical record revealed the lack of documentation indicating that the resident had been provided education regarding the risks and benefits of the influenza and pneumococcal vaccines. 2. Resident 2 was admitted to the facility on [DATE] with several [DIAGNOSES REDACTED]. During the initial tour on 1/23/12, a licensed nursing staff described the resident as able to makes needs known with mumbled speech, and that he occasionally had family members and a significant other visiting. Review of the minimum data set ((MDS) dated [DATE] indicated that the resident was dependent on staff for all activities of daily living. Review of the MDS dated [DATE] revealed that Resident 2 did not receive the influenza vaccine at the facility for the current influenza season and that it was not offered. In addition, the MDS noted that the resident's pneumococcal vaccination was not up to date and that the vaccine was also not offered. In spite of this, the facility tracking log for influenza and pneumococcal vaccinations revealed that Resident 2 received the influenza vaccine on 1/11/12, and that he refused the pneumococcal vaccine. Further review of medical record however revealed the lack of documentation that the resident or the resident's legal guardian was provided education about the risks and benefits of both the influenza and pneumococcal vaccines. 3. Review of the facility's policy and procedures on Administering Influenza Vaccines (revised 08/2009) revealed that the policy did not meet certain elements specified under 483.25)(n) including that: a. before offering the influenza immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; b. that each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; c. that the resident or the resident's legal representative has the opportunity to refuse immunization; and d. that the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's legal representative was provided education regarding the benefits and potential side effects of influenza immunization; and that the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. Further, the facility did not have policies and procedures in place specific to pneumococcal vaccinations to ensure that: a. before offering the pneumococcal immunization, each resident, or the resident's legal representative receives education regarding the benefits and potential side effects of the immunization; b. each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; c. the resident or the resident's legal representative has the opportunity to refuse immunization; and that d. the resident's medical record includes documentation that indicated, at a minimum, the following: the resident or resident's legal representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and that the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal. During the same interview on 1/25/12, the licensed nursing staff stated that the facility had policy and procedures for Administering Influenza Vaccines. Review of the document however revealed that while the document clarified licensed nursing staff responsibility in the assessment of high-risk target groups and the administration of the influenza vaccine, it did not include pneumococcal vaccinations and how this was to be monitored and offered to residents. In addition, the policy did not have provisions that included the elements referenced above. | 2017-01-01 |