cms_HI: 25
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 |
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 25 | KULA HOSPITAL | 125003 | 100 KEOKEA PLACE | KULA | HI | 96790 | 2017-04-21 | 334 | F | 0 | 1 | 1M3411 | **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview with staff members and review of the facility's policy and procedure, the facility failed to ensure 5 (Residents #70, #63, #34, #56 and #57) of 5 residents sampled for immunization had the opportunity to refuse the influenza vaccine. The resident's medical record does not include documentation that the resident or resident's representative was provided with education regarding the benefits and potential side effects of the influenza immunization and the resident received the immunization or refused the vaccination. Findings include: On 4/10/17 the facility provided a copy of the the policy and procedures for Vaccination Pneumococcal and Influenza Inpatient Protocol. The procedure includes if a resident is indicated for the vaccine, the facility will provide the :Vaccine Information Statement (VIS) and will review the appropriate VIS with the resident prior to the administration of the vaccine. The required documentation includes: patient/family education; the date of administration of the pneumococcal vaccine; amount and dosage given; the site of injection; the vaccine manufacturer; the lot number of the vaccine used; the expiration date of the vaccine; and signature of licensed nurse administering the vaccine. The policy did not include provision for the resident or resident's representative to refuse immunization. On 4/13/17 at 9:00 [NAME]M. an interview was conducted with the Director of Nursing (DON) and Staff Member #122. The staff members reported the process for immunizations include sending a letter to the resident or resident's representative to offer the vaccine with the VIS attached. The letters are sent out in (MONTH) and November. Staff Member #122 provided a sample of the immunization packet that is sent to the resident or resident's representative. The letter was reviewed during the interview which notifies the resident or resident's representative that All residents at (facility name) are scheduled to receive: flu vaccine annually; tetanus/[MEDICATION NAME] vaccine - given every [AGE] years, or as medically necessary; tetanus/[MEDICATION NAME]/peruses ([MEDICATION NAME]) - given one time for adults [AGE] years or older; and pneumococcal (a type of pneumonia) - given at age 65 with a second for those people aged 65 and older who got their first does under the age of 65 if five or more years have passed. The letter also documents that the physician has ordered these vaccines and will administer as ordered unless contraindicated. There was no information related to declination of the vaccines. Upon review of this letter, the DON stated the letter informs the recipient of the letter of the right to refuse the vaccines. Staff Member #122 reviewed the letter and confirmed there is no information regarding declining administration of the vaccines. Staff Member #122 reviewed the VIS documents in the packet and found the information statement for the [MEDICATION NAME] vaccine was dated 2/24/2015 which indicates the date when the form was updated, acknowledging the form may have been revised since (YEAR) and the facility may not be providing the most current information (VIS) related to vaccines. The inconsistent process for the five sampled residents was shared during this interview. The inconsistencies included letters that were not dated, letters that were dated and not signed, no documentation education was provided to the resident or resident's representative and no opportunity for the resident to refuse the immunization. Staff Member #122 commented the facility will definitely tighten the process for immunizing the residents. 1) On 4/11/17 an interview and concurrent record review was done for Resident #63 with Staff Member #155. Staff Member #155 confirmed the resident received the flu vaccine on 10/7/16 and the [MEDICATION NAME] on 6/18/16. The staff member reported the resident or representative is provided with information regarding the vaccine on admission then once a year the resident or representative is contacted. The staff member reported staff members are to document in the progress note that education was provided. The staff member referred to the Interdisciplinary Patient/Resident and Family Teaching Record form that documents education was provided to the resident or resident's representative. The staff member could not find documentation on the form that education was provided to the resident and/or representative. The staff member also reviewed the progress note and confirmed there was no documentation in the progress notes related to education and there was no documentation that the resident and/or representative had an opportunity to decline the vaccine. Further review found a letter dated 6/15/16 regarding vaccines informing residents that vaccines (annual influenza vaccine, tetanus/[MEDICATION NAME] and peruses and a pneumococcal vaccine) will be ordered by their physician. Also noted was an enclosed CDC Fact Sheets. This letter was not signed by the Acting DON. This letter was not the same letter that was included in the packet provided by the DON and Staff Member #122. There was documentation of a second letter dated 7/19/16 which was signed by the Acting DON. The letters sent to the resident or resident's representative did not include information to refuse vaccines. 2) On 4/12/17 at 8:52 [NAME]M. an interview and concurrent record review was done for Resident #34 with Staff Member #155. The review found a letter dated 6/15/16 regarding vaccines that will be ordered by the physician which was not signed by the Acting DON. There was another letter dated 7/19/16 which was signed by the Acting DON. The letter in the resident's medical record was not the same letter provided by the staff members during the interview. Subsequently, Staff Member #155 found the Interdisciplinary Patient/Resident and Family Teaching Record which documents on 6/30/16, 8/30/16 and 9/8/16 education was provided regarding vaccinations to the resident. The documentation on this form consisted of the staff member writing the number 8 for vaccinations in the topic/learning objectives column. There was no progress note to document the specifics of the education that was provided. A review of the physician's orders [REDACTED]. There was no documentation that the resident had an opportunity to refuse the vaccine. 3) A review of Resident #70's medical record on the morning of 4/11/17 at 2:55 P.M. revealed she received the Influenza vaccine for the (YEAR) flu season on 10/5/16. The documentation regarding the vaccine was incomplete and did not show how the facility discussed the risks and benefits with Resident #70's Power of Attorney (POA) for receiving the flu vaccine. An interview of the Nurse Manager on the afternoon of 4/11/17 at 2:55 P.M. revealed the facility did not educate the POA for the risks/benefits of the Influenza vaccine. 4) On 4/12/17, a chart review of Resident #56's (R #56) immunization status for influenza and pneumococcal vaccines was done. There was no clinical documentation to show the resident or the resident's representative received the vaccine information statements, including the benefits and risks of both immunizations, and the administration or the refusal of, or medical contraindications to the vaccines. In addition, the vaccine information statements (VIS) forms sent out were for the (YEAR) year, and not the current year for (YEAR). On 04/13/2017 at 7:21 AM, Staff #108 confirmed for R #56, she had received verbal consent from the resident's guardian to administer the vaccines. Staff #108 verified however, there was no documentation in the resident's progress notes about the verbal consent. Staff #108 also said the teaching record the facility used to chart when the VIS was sent out was a process being done on every unit. She acknowledged both the consent and/or declination had to be documented, but that it was not done. 5) In the morning of 4/15/2016 a concurrent record review was done with Staff #58 for Resident #57. Res #57 received an influenza vaccine in (YEAR). Staff #58 was asked to show evidence of the influenza vaccine education provided to resident #57 or POA prior to administration of the vaccine. Staff #58 showed a facility paper in the resident record with a checkmark to topic #8 verbal paperwork sent to family 7/20/16. When asked for evidence for consent for immunization. Staff #58 stated a telephone call was made to the resident's son around that time and the son agreed to the vaccine for the resident. There was no written evidence provided by staff for consent for vaccination or education on side effects and benefits of the vaccine. Failure to provide documented education on the vaccine side effects and benefits; and consent to vaccinate prior to vaccination potentially violates the resident's informed consent rights. | 2020-09-01 |