Health inspection·May 15, 2023

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the facility failed to ensure: Residents Affected - Some 1. Pneumococcal (PNA-infection that inflames air sacs in one or both lungs and can be life-threatening to anyone but particularly to infants, children, and people over [AGE] years old) vaccine was offered and/or administered (when consented), to three of five sampled residents. (Resident 1, 2, and 3). 2. Influenza (Flu-common viral infection that can be deadly, especially in high-risk groups) vaccine was offered to four of five sampled residents (Resident 1, 2, 3, and 4) These deficient practices placed Residents 1, 2, 3 and 4 at a higher risk of possibly acquiring and transmitting Flu and/or PNA infections to other Residents, Visitors and Staff. Findings: 1. A review of the facility's policy titled, Pneumococcal Vaccine dated March 2022, indicated, All residents are offered pneumococcal vaccines to aid in preventing pneumonia/pneumococcal infections. Pneumococcal vaccines are administered to residents (unless medically contraindicated, already given, or refused) per our facility's physician-approved pneumococcal vaccination protocol. 1.a. A review of Resident 1's admission Record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of lung disease, dementia, and altered mental status. Resident 1 was over [AGE] years old and was unable to make her own decisions regarding her health care. No contraindications to receiving vaccinations were noted in her medical record. A review of Resident 1's medical record revealed there was no documentation concerning her PNA vaccine status. During a concurrent record review and interview with Licensed Nurse (LN) A, on 5/9/23 at 12:15 pm, Resident 1's medical records were reviewed. LN A confirmed there was no documentation that Resident 1 was offered or received the PNA vaccine. During a concurrent record review and interview with the Infection Preventionist (IP), on 5/9/23 at 3:21 pm, Resident 1's immunization records were reviewed. IP presented a document titled, Immunization Consent for Resident 1, which was signed by the Director of Nursing on 4/28/21, indicating that, Resident unable to sign/consent for self. The PNA vaccine accept/decline check boxes were blank. The IP confirmed Resident 1's PNA vaccine status should have been followed up on with her conservator, Page 1 of 3 055807 055807 05/15/2023 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0883 but they were not. Level of Harm - Minimal harm or potential for actual harm 1.b. A review of Resident 2's admission Record indicated Resident 2 was admitted to the facility on [DATE] with the diagnoses of sepsis (the body's extreme reaction to an infection), respiratory disease and a urinary tract infection. He was over [AGE] years old and able to make his own decisions. No contraindications to the PNA vaccine were noted in his medical record. Residents Affected - Some A review of Resident 2's Immunization Program Resident Permission signed by Resident 2 on 10/2/21, indicated Resident 2 agreed to receiving the PNA vaccine. There was no documentation in Resident 2's medical records confirming he received the PNA vaccination. During concurrent chart review and interview with LN A on 5/9/23 at 12:15 pm, Resident 2's chart was reviewed. LN A confirmed that Resident 2 requested the PNA vaccine in 2021 but she was unable to provide documentation that he received it. During concurrent medical record review and interview with IP on 5/9/23 at 12:15 pm, Resident 2's medical record was reviewed. The IP stated, If he wanted it, he should have gotten it. She confirmed that Resident 2 had no documentation in his medical record of receiving the PNA vaccination. The IP indicated she was having trouble following through with immunizations because she was busy doing Staff Development and Infection Control responsibilities and sometimes things fell through the cracks. 1.c. A review of Resident 3's medical record revealed he was admitted on [DATE] with the diagnoses of rib fractures, depression and anxiety. He was over [AGE] years old and was able to give consent for himself. No contraindications to vaccinations were noted in his medical record. During a review of Resident 3's Observation Detail List Report Immunization Consent dated 1/25/23 by LN A, the consent form indicated Resident 3's desired to have a PNA vaccine. The document was signed by Resident 3 and dated 1/25/23. During an interview on 5/9/23 at 12:15 pm, LN A searched through Resident 3's medical record and then indicated she was unable to provide documentation that Resident 3 had received the PNA vaccine. During a concurrent record review and interview with the IP on 5/9/23 at 3:21 pm, Resident 3's immunization records were reviewed. The IP confirmed that Resident 3 had agreed to receiving the PNA vaccine but had never received it. 2. A review of the facility's policy titled, Influenza Vaccine dated March 2022, read All residents and employees who have no medical contraindications to the vaccine will be offered the influenza vaccine annually to encourage and promote the benefits associated with vaccinations against influenza. Between October 1st and March 31st each year, the influenza vaccine shall be offered to residents and employees, unless the vaccine is medically contraindicated .for those who receive the vaccine, the date of vaccination, lot number, expiration date, person administering, and the site of vaccination will be documented in the resident's/employee's medical record. 2.a. A review of Resident 1's medical record revealed no documentation indicating a refusal or acceptance for the flu vaccination for the 2022-23 year. During a concurrent record review and interview with LN A on 5/9/23 at 12:15 pm, Resident 1's medical records were reviewed. LN A confirmed there was no documentation that Resident 1 was offered the 055807 Page 2 of 3 055807 05/15/2023 Shasta Healthcare 445 Park Street Weed, CA 96094

F 0883 Flu vaccine for the 2022-23 year. LN A indicated the IP was responsible for Immunizations. Level of Harm - Minimal harm or potential for actual harm During a concurrent record review and interview with the IP on 5/9/23 at 3:21 pm, Resident 1's immunization records were reviewed. The IP presented a document titled, Immunization Consent for Resident 1 which was signed by the Director of Nursing on 4/28/21 indicating, Resident unable to sign/consent for self. The Flu vaccine accept/decline check boxes were blank. The IP confirmed Resident 1's immunizations should have been followed up on with her conservator and they were not. Residents Affected - Some 2.b. A review of Resident 2's medical record revealed there was no documentation indicating a refusal or acceptance for the Flu vaccination for the 2022-23 year. During a concurrent record review and interview with LN A on 5/9/23 at 12:15 pm, Resident 2's immunization record was reviewed. LN A confirmed there was no documentation that Resident 2 was offered the Flu vaccination for the 2022-23 year. During concurrent record review and interview with the IP on 5/9/23 at 3:21 pm, Resident 2's medical chart was reviewed. IP confirmed Resident 2 had not been offered the Flu vaccine for the 2022-23 year and he should have been. 2.c. During a review of Resident 3's, Observation Detail List Report Immunization Consent dated 1/25/23 by LN A, the consent form indicated Resident 3's wishes were to accept the Flu vaccine. The document was signed by Resident 3 and dated 1/25/23. During an interview on 5/9/23 at 12:15 pm, LN A searched through Resident 3's chart and then indicated she was unable to provide documentation that Resident 3 had received the Flu vaccine. During a concurrent record review and interview with the IP on 5/9/23 at 3:21 pm, Resident 3's immunization records were reviewed. The IP confirmed that Resident 3 had agreed to receive the Flu vaccine but had never received it for the 2022-23 year. She indicated the nurse admitting the resident was responsible for educating the resident and obtaining their signed decision concerning immunizations. The signed form was then put into the Resident's chart for someone to follow up on. The IP said it had been a while since she had time to follow up on new residents' immunization records. The IP indicated that her expectations were for the admitting nurse to follow through with administering the vaccine. 2.d. A review of Resident 4's medical record revealed he was admitted on [DATE] with diagnoses of lung disease, stroke, and dementia. He was over [AGE] years of age and was not able to make his own decisions. No contraindications to vaccinations were noted in his medical record. A review of Resident 4's Preventive Health Care. Vaccinations (undated), record indicated Resident 4 received the Flu vaccine on 10/9/19, 11/15/20, and 11/16/21. There was no record of Resident 4 being educated, offered, or receiving the Flu vaccination for the 2022-23 year. During a concurrent record review and interview with the IP, on 5/9/23 at 3:21 pm, Resident 4's immunization records were reviewed. The IP confirmed that Resident 4 had not received the 2022-23 Flu vaccine because she was unable to get a hold of his Responsible Party (a person who makes decisions for a resident when the resident was unable to) during the time she was giving Flu vaccinations. The IP indicated this should have been followed up on and it was not. 055807 Page 3 of 3