Failure to Administer Pneumococcal Vaccine to Residents
Penalty
Summary
The facility failed to ensure that two residents, identified as R15 and R40, received the pneumococcal vaccine as part of their immunization protocol. R40 was admitted with multiple diagnoses including diabetes mellitus, chronic kidney disease, and congestive heart failure. Although R40 consented to the pneumococcal vaccine on 8/9/22, his immunization report printed on 4/8/25 did not document the administration of the vaccine. Similarly, R15, who was admitted with conditions such as progressive neuropathy and Alzheimer's disease, also lacked documentation of receiving the pneumococcal vaccine as of 4/8/25. Interviews with the Director of Nursing (V2) and the Social Service Director (V14) revealed that the facility's process involves social services discussing and reviewing immunizations with residents upon admission. The facility's policy, revised on 11/28/16, states that the pneumococcal immunization is offered on admission if no prior history is available. However, the records for R15 and R40 did not reflect the administration of the vaccine, indicating a lapse in following the established protocol. The CDC's guidelines, which the facility claims to follow, recommend that adults over 50 who have not received a pneumonia vaccine should receive the PCV 20 vaccine.