Failure to Offer and Document Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal immunizations and received education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey for two residents. Resident #9, who had a diagnosis of [DIAGNOSES REDACTED], was cognitively impaired and dependent on staff for daily activities. There was no documented evidence that this resident or their representative received education about, was offered, or declined the pneumococcal vaccine. Similarly, Resident #50, with a diagnosis of [DIAGNOSES REDACTED] and severe cognitive impairment, also lacked documentation of being offered the vaccine or receiving education about it. The Director of Nursing, who also served as the Infection Preventionist, acknowledged during an interview that they were responsible for the vaccine program and documentation of each resident's vaccine status upon admission. However, they admitted to not closely monitoring the pneumococcal vaccines for residents and failing to track the vaccine information. This oversight led to the deficiency, as the facility did not adhere to its policy of offering pneumococcal vaccinations to all residents to prevent the spread of infectious disease and mitigate associated risks.
Plan Of Correction
Plan of Correction: Approved February 28, 2025 F883 Ss=D The Plan of Correction is submitted in compliance with applicable law and regulation. To demonstrate continuing compliance with applicable law, the center has taken or will take actions set forth in following alleged deficiency. How corrective actions will be accomplished for residents found to have been affected by deficient practice: 1. Residents #9 and #50 were reviewed and offered education to resident or primary advocate on pneumococcal vaccine with documentation provided that residents #9 and #50 received pneumococcal vaccine in house on 2/19/25. All residents have the potential to be affected by this practice - Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. No additional issues found. Measures put in place or systemic changes made to ensure that the deficient practice will not reoccur: - The Policy titled Pneumococcal vaccine was reviewed by Director of Nursing and Administrator on 2/25/25, with no revisions needed. - The director of nursing/infection preventionist will educate the unit managers and charge nurses on pneumococcal vaccines, providing education/information pamphlet and proof of consent or declination. - The director of nursing/infection preventionist will ensure residents who were offered the pneumococcal vaccine were educated and documentation of refusal or consent is logged. How facility plans to monitor performance to make sure the solutions are sustained: To ascertain the effectiveness of the education and audit was developed. The Director of Nursing/infection preventionist/Designee will perform an Audit for all residents residing in the facility who are eligible for pneumococcal vaccine and are being provided with education/information pamphlet, consent and declinations are being obtained. Eligible residents will be audited weekly for 3 months for long term residents. Audit for new admission will be done weekly x 3 months. Any discrepancies will be immediately corrected and staff re-educated and/or counseled as needed. The results of the Audit will be reported at monthly QAPI.