Angel McGarrity-Davis, RN, CDONA, NHA

I am a new assistant director of nursing and my administrator asked me to oversee immunizations. Where do I start? 

The first thing you should do is review the facility policy and procedure: It should have everything that you need to know and do for that particular facility/company. If not, here’s a synopsis.  

There are specific regulations that I will send you to review, F-334, F-441 and QIS pathway “Infection Control and Immunizations.” Surveyors will be pulling residents from census during October 1-March 31, to ensure the following is completed and accurately documented in the medical record. 

An overview of the program:

1. Before offering the immunization, each resident and his or her family or responsible party should receive education on the benefits and potential side effects of the immunization.   

2. Each resident should be offered an immunization unless medically contraindicated or the resident has previously been immunized.  

3. The resident or the resident’s legal representative has the opportunity to refuse the immunization.  

4. The resident’s medical record includes the documentation that the information was provided as was the education, as stated above. Also, it should include the documentation that the immunization was administered or was refused.   

5. Be prepared for an outbreak, make sure your interdisciplinary team is using preventative measures and start NOW!   

Strategies to overcome barriers 

• Use a standard form to record all vaccines for each resident.  

• Implement standing orders through your QAPI program.

• Use incentive programs.

• Try to instill this as a culture change for your staff and residents.