Failure to Offer Updated Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer a resident, identified as R28, the opportunity to receive flu and pneumonia vaccinations in accordance with nationally recognized standards. The facility's policy on immunizations, dated May 22, 2024, was not updated to reflect the current CDC recommendations. The CDC guidelines indicated that adults of a certain age have the option to receive Prevnar 20 (PCV20) or PCV21, or to not receive additional pneumococcal vaccines, depending on their vaccination history. However, R28's electronic medical record did not show any indication of being offered the PCV20 or PCV21 vaccine after receiving previous pneumococcal vaccinations, specifically Pneumovax 23 in 2010 and PCV13 in 2015. Interviews with the Director of Nursing (DON) and the Administrator revealed that the facility relied on a state online system for immunization records, which did not have updated CDC guidance. The DON acknowledged the importance of following CDC recommendations, while the Administrator admitted that the facility failed to identify and apply the current CDC recommendations to their policy. This oversight had the potential to place R28 at risk of contracting pneumonia and other residents at risk of not being offered immunizations based on current guidelines.