Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer and/or provide the pneumococcal immunization to a resident, despite having a signed consent form. The facility's policy, last reviewed on September 16, 2024, mandates that each resident should be offered a pneumococcal immunization unless it is medically contraindicated. Additionally, nursing staff are required to provide educational information to the resident or their authorized representative before administering the vaccine, and a signed consent form must be obtained. In this case, Resident 29, who was admitted with diagnoses including atherosclerotic heart disease, dementia, and diabetes, had a signed consent form dated July 18, 2024, indicating permission for the pneumococcal vaccine. However, upon review of Resident 29's clinical record, there was no documented evidence that the pneumococcal vaccine was administered as per the signed consent. This deficiency was confirmed during an interview with the Director of Nursing on January 16, 2025. The failure to administer the vaccine as requested is a violation of several Pennsylvania codes related to the responsibility of the licensee, management, medical records, and resident care policies.
Plan Of Correction
1. Resident 29 was administered a PNA vaccination. 2. A facility wide audit was completed to ensure residents that want the PNA vaccination were offered it and received it. 3. The Infection Control Nurse was re-educated on ensuring PNA vaccinations are administered to residents wanting them. The DON will complete random vaccination administration audits to ensure that they are administered per resident preference. 4. The DON or designee will conduct an audit of new admissions weekly x 4 weeks then monthly x 2 months to ensure those that want the PNA vaccination receive it timely. The results will be submitted to the QAPI Committee for review and analysis of need for ongoing monitoring.