Failure to Offer Pneumococcal Vaccinations and Education
Penalty
Summary
The facility failed to ensure that residents were offered pneumococcal immunizations and provided with education regarding the benefits and potential side effects of the immunizations. This deficiency was identified during a recertification survey, where it was found that two residents did not have documented evidence of being offered the pneumococcal vaccination, nor did they receive education about it. Resident #1, who had intact cognition, had not been offered the vaccination since their last recorded dose in 2001. Similarly, Resident #24, admitted with specific diagnoses, had not been offered the vaccination since their last recorded dose in 2012. Interviews with facility staff revealed that there was no documentation available for these residents regarding the offer and education of the pneumococcal vaccination. The Administrator acknowledged the lack of documentation and attributed it to nursing staffing shortages and turnover. The Director of Nursing confirmed that a declination form should be signed and uploaded to the electronic medical record if a resident refused a vaccination, and that the pneumococcal vaccination should be offered to all eligible residents at admission and/or every five years.
Plan Of Correction
Plan of Correction: Approved April 4, 2025 F883 P(NAME) Description: I. Immediate Corrective Action Resident #1 and resident #24 were immediately offered education regarding the risks and benefits of the pneumococcal vaccine as well as offered the vaccine itself. II. Identification of others All residents have the potential to be affected by the deficient practice. All Resident Charts will be audited to determine if they received their pneumococcal vaccine, declined, and received education. All negative findings were rectified immediately. III. Systematic Changes The Policy and procedure regarding pneumococcal vaccines was reviewed and determined to be in compliance. An in-service will be provided to all LPNs and RNs to educate them that the resident and/or representative has a right to receive education, receive or decline the pneumococcal vaccine as well as documented in the resident CCP. All consents and/or declinations will also be uploaded to the document section of Sigma. IV. QA monitoring a. An audit tool was developed to ensure that all residents and/or representatives receive education, receive or decline the pneumococcal vaccine. Audits will be conducted weekly for 4 weeks and monthly for 11 months. Any negative findings from the audits will be corrected immediately. b. Audits will be brought to QA meeting. V. Title Responsible a. Director of Nursing