Deficiency in Offering and Documenting Vaccinations
Summary
The facility failed to ensure that each resident was offered influenza and pneumococcal immunizations, and that education was provided regarding the benefits and potential side effects of these immunizations. Additionally, the facility did not document that residents or their representatives were given the opportunity to refuse these immunizations unless they were medically contraindicated or previously administered. This deficiency was identified for one of the five residents reviewed, specifically Resident #134, who had a moderately impaired cognition and a complex medical history including conditions such as hypotension, cerebral infarction, and chronic heart failure. The surveyor observed that there was no documentation in the electronic medical record (EMR) for Resident #134 regarding the offering or refusal of influenza and pneumococcal vaccines. The facility's records, including the Immunization tab and the personalized care plan, lacked evidence of any focus on immunization status or education provided to the resident or their representative. Interviews with the Registered Nurse Coordinator (RNC) and the Infection Preventionist Nurse (IPN) revealed inconsistencies and gaps in the facility's protocol for tracking and documenting immunizations, with no clear process for offering vaccines upon admission or during the flu season. Further investigation showed that the facility's policies and procedures for influenza and pneumococcal vaccinations were not effectively implemented. The IPN admitted to not tracking pneumococcal vaccinations and was unable to provide a tracking log for resident vaccinations. The facility's management, including the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON), were informed of these findings, but no additional information or refutation of the findings was provided during the exit conference.
Penalty
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Incomplete pneumococcal vaccine documentation was identified for three residents. The facility policy required admission review of prior immunizations and documentation in the EHR, but records for residents with DM, HTN, CAD, MS, and COPD showed pneumococcal status coded as not up to date and not offered, while the immunization entries listed consent not obtained or status to be determined, with education not checked for two residents and no documented evidence that vaccine status was discussed with the attending physician for one resident. The DON acknowledged the facility failed to provide accurate and timely documentation related to the pneumonia vaccine.
The facility failed to consistently educate, offer, or administer influenza and pneumococcal vaccines for multiple residents. Records for one resident did not clearly show prior vaccine history or eligibility, another resident had no evidence of shared decision making or additional pneumococcal vaccination, and a third resident’s consent was incomplete and lacked documentation of vaccination. The IP nurse stated she handled MIIC review and PCC entry herself and that vaccine review was behind during a period when she was also serving as DON.
Pneumococcal immunization education and offer process deficient: The facility did not provide accurate education about current CDC guidance for PCV20/PCV21 and did not ensure that eligible residents were reoffered pneumococcal vaccine during ongoing stay. One resident’s declination form incorrectly stated no further vaccine was needed after PCV13 and PPSV23, another resident’s son declined based on outdated information, and two other residents had no evidence of a later vaccine offer after becoming eligible.
Failure to Offer Recommended Pneumococcal Vaccinations: The facility did not document offering the recommended pneumococcal vaccine to three residents who had prior pneumococcal immunizations. EMR review showed one resident had received PCV13, another had received PCV13, and a third had received PPV23, but there was no record that any of them were offered, received, or declined the additional recommended vaccine. The RN unit manager/IP acknowledged the residents were not offered the vaccines and had not refused them.
A facility failed to ensure one resident received a pneumococcal vaccine after consent was obtained, with no documentation that it was administered or contraindicated. The facility also failed to document that another resident was offered the influenza vaccine and refused it, despite the MDS indicating the vaccine was not received in the facility. The DON confirmed the missing documentation for both residents.
Failure to document vaccine education and refusals for two residents. One resident with type 2 DM and another resident with respiratory failure both had BIMS scores of 15/15, but their records showed refusal of PCV 20 and refusal of influenza and pneumococcal vaccines without documentation that education on benefits and risks was provided. The IP stated education was provided regardless of refusal, while the DON confirmed the records lacked documentation of vaccine education.
Incomplete Pneumococcal Vaccine Documentation
Penalty
Summary
Failure to develop and implement policies and procedures for flu and pneumonia vaccinations was identified after review of facility policy, clinical records, and staff interview. The facility policy dated 5/4/26 stated that residents or responsible parties would be asked about prior vaccinations at admission, prior doses of influenza, pneumococcal, COVID, and other vaccines would be documented in the immunization portal in the electronic health record, and vaccinations would be administered by provider orders. For Resident R4, who was admitted with diabetes, depression, and multiple sclerosis, the MDS dated 6/19/26 coded pneumococcal vaccine status as not up to date and reason as not offered. The immunization record showed consent was not obtained and the reason was status to be determined, with education to the resident or representative not checked. For Resident R26, admitted with diabetes, high blood pressure, and coronary artery disease, the MDS also coded pneumococcal vaccine status as not up to date and reason as not offered, but the immunization record showed consent was not obtained and the reason was unable to obtain data, with no documented evidence that the vaccine status was discussed with the attending physician. For Resident R72, admitted with high blood pressure, chronic pain, and COPD, the MDS coded pneumococcal vaccine status as not up to date and reason as not offered, and the immunization record showed consent was not obtained and the reason was status to be determined, with education to the resident or representative not checked. The DON stated the facility should have followed up with vaccinations and confirmed the facility failed to provide accurate and timely documentation related to the pneumonia vaccine for these residents.
Failure to Consistently Manage Flu and Pneumococcal Immunizations
Penalty
Summary
The facility failed to consistently educate, offer, or administer influenza and pneumococcal immunizations for 3 of 5 residents reviewed for immunizations. For one resident, the admission record and vaccination consent did not identify whether prior influenza or pneumococcal vaccines had been received or whether the resident wanted or was eligible for the vaccines, and the consent was marked "No!" with a health unit coordinator signature. The resident’s EMR showed prior receipt of Prevnar 13 and influenza vaccine, and the CDC indicated the resident was eligible for shared decision making with the provider regarding PCV20 or PCV21 because more than one year had passed since the Prevnar 13 dose. For another resident, the record did not include evidence of shared decision making or receipt of an additional pneumococcal vaccine. A third resident’s vaccination consent indicated prior pneumococcal vaccines and that the resident would like to receive the vaccine, but the form was not signed by the resident or representative, and the record did not show shared decision making or receipt of vaccination. During interview, the infection prevention and control nurse stated she was responsible for reviewing MIIC reports, uploading them to PCC, and entering immunizations, and that she was the only person doing the vaccine review. She also stated that two of the admissions occurred during a time when she was serving as DON and things were behind. The facility policy required an immunization history on admission, review of MIIC, sharing unknown or noncurrent immunizations with the attending physician, obtaining orders, and documenting immunization history and education in the EMR.
Pneumococcal Immunization Education and Offer Process Deficient
Penalty
Summary
The facility failed to provide accurate education regarding pneumococcal immunization and failed to ensure that each resident was offered a pneumococcal immunization unless medically contraindicated for four of five residents reviewed for immunization concerns. The facility policy stated that residents would be offered pneumococcal vaccines at admission and ongoing as needed, with administration based on current CDC recommendations, but the policy did not specify how often residents would receive education about pneumococcal immunizations or how often they would be offered vaccines during ongoing admission. Resident 157 was admitted with a history of receiving Prevnar 13 and Pneumovax, and based on shared clinical decision-making was eligible for PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine. Although a declination form dated at admission showed the resident declined a pneumococcal vaccine, there was no evidence the facility reoffered the vaccine during the two years since admission. Resident 177 had previously received Pneumovax 23 and Prevnar 13 and was also eligible for PCV20 or PCV21 after 5 years, but her son declined the vaccine at admission because he believed she had already received it, and there was no evidence the facility educated him that current CDC guidance supported PCV20 or PCV21. Resident 11 had received Pneumovax 23 years earlier, and the consent/declination form stated she declined because she already received the vaccine, but the form incorrectly indicated that no further vaccination was warranted if both PCV13 and PPSV23 had been given and did not reflect current CDC guidance for PCV20 or PCV21 after 5 years. Resident 17 had received Prevnar 13 and Pneumovax 23 and was eligible for PCV20 or PCV21 five years after the last dose, but the record contained no evidence that the facility offered the vaccine after that time. The infection control prevention coordinator confirmed the facility’s pneumococcal immunization plan and the findings for these residents.
Failure to Offer Recommended Pneumococcal Vaccinations
Penalty
Summary
The facility failed to minimize the risk of residents acquiring and transmitting pneumococcal disease by not ensuring that three sampled residents were offered the recommended pneumococcal vaccination. Resident 35’s EMR showed admission to the facility and prior receipt of PCV13 on 8/21/20, but there was no documentation that he was offered, received, or declined the additional recommended pneumococcal vaccine. Resident 56’s EMR showed admission to the facility and prior receipt of PCV13 on 11/21/19, with no documentation that he was offered, received, or declined the additional recommended pneumococcal vaccine. Resident 60’s EMR showed admission to the facility and prior receipt of PPV23 on 11/12/10, but there was no documentation that he was offered, received, or declined the additional recommended pneumococcal vaccine. During interview, the RN unit manager/infection preventionist stated that the facility had started using a new computer system on 6/1/26 to monitor immunizations and that residents were offered needed immunizations based on the new system and state immunization records. She agreed that residents 35, 56, and 60 were not offered the recommended pneumococcal vaccines and did not decline or refuse them. The updated 6/19/25 pneumococcal vaccination policy stated that the facility offers pneumococcal vaccination in accordance with CDC recommendations and federal requirements and that each resident’s pneumococcal immunization status is determined upon admission or soon afterward and documented in the EHR.
Failure to Document and Provide Pneumococcal and Influenza Vaccinations
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were administered for one resident and failed to ensure that influenza vaccination documentation was complete for another resident. The facility’s pneumococcal vaccine policy, dated May 29, 2026, stated that all residents would receive immunizations and/or vaccinations to help prevent infectious disease unless medically contraindicated or refused. A quarterly MDS assessment for Resident 83 dated June 18, 2026, showed the resident was cognitively intact, needed staff assistance with daily care needs, and that the pneumococcal vaccination was not up to date and had not been offered. A Pneumococcal Pneumonia Immunization Consent Form dated March 20, 2026, showed education was provided and authorization to administer the vaccine was obtained, but there was no documented evidence that the vaccine was given or that it was contraindicated. An annual MDS assessment for Resident 6 dated February 13, 2026, showed the resident was cognitively intact, needed staff assistance with daily care needs, and did not receive the influenza vaccine in the facility for that flu season because it was offered and refused. However, there was no documented evidence that the resident was offered the influenza vaccine during the 2025-2026 flu season or that she refused it. The DON confirmed that Resident 83 had signed consent for the pneumococcal vaccine but there was still no documentation that it had been administered, and also confirmed there was no documented evidence that Resident 6 was offered the influenza vaccine and refused it.
Failure to Document Vaccine Education and Refusals
Penalty
Summary
The facility failed to document in the medical record the education and information provided regarding influenza and pneumococcal vaccinations for two residents. Resident 27 was admitted with diagnoses including type 2 diabetes and had an MDS dated 7/3/26 showing a BIMS score of 15/15, indicating cognitive intactness. Resident 27's Immunization Details dated 5/19/26 showed refusal of the PCV 20 vaccine, but there was no documented evidence that education on the benefits of vaccination or the risks of not receiving it was provided before the refusal. Resident 100 was admitted with diagnoses including respiratory failure and had an MDS showing a BIMS score of 15/15, indicating cognitive intactness. Resident 100's Immunization Details dated 7/13/2026 showed that both the influenza and pneumococcal vaccines were declined, and the record indicated that no educational information was provided about either vaccine. During interviews, Resident 100 stated he was never educated on the influenza and pneumococcal vaccines, and Resident 27 stated he was never offered the pneumococcal vaccine and would have taken it had it been offered and education provided. The IP stated education on vaccination was provided regardless of refusal, while the DON confirmed there was no documentation that education was provided to either resident and stated staff were expected to educate residents and document it in the record.
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