Failure to Administer Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that residents who requested the pneumococcal vaccine were provided with the vaccination. This deficiency was identified for six out of seven residents reviewed, specifically Residents R43, R54, R56, R64, R69, and R70. Each of these residents had consented to receive the pneumococcal vaccination, as documented in their Pneumococcal Vaccine Informed Consent/Declination forms. However, a review of their clinical records revealed that the vaccine was not administered to any of these residents. The facility's policy on pneumococcal vaccination, which was last reviewed on January 18, 2024, mandates that all residents be offered the vaccine to prevent pneumonia and pneumococcal infections. Despite this policy, the clinical records for the aforementioned residents did not show evidence of the vaccine being provided. This was confirmed during interviews with the Infection Preventionist RN and the Nursing Home Administrator, along with the Director of Nursing, who acknowledged the oversight in providing the requested vaccinations.
Plan Of Correction
1. R43, R54, R56, R64, R69, and R70 records reviewed to confirm their current consents and medical eligibility to receive the pneumococcal vaccine. 2. The Director of Nursing/Designee will arrange for the immediate administration of the pneumococcal vaccine to all residents requesting vaccination. 3. The Director of Nursing/Designee will provide retraining for all nursing and relevant medical staff on the facility's immunization protocols, specifically focusing on the importance of adhering to resident requests for vaccinations and assessing vaccine eligibility. 4. The Director of Nursing/Designee will ensure this system allows for easy retrieval of vaccination records to facilitate ongoing compliance and audits. 5. The Director of Nursing/Designee will schedule audits for all new admissions weekly for two weeks then monthly for two months. Findings will be submitted to be reviewed during the monthly Quality Assurance and Performance Improvement (QAPI) meetings.