Failure to Offer and Educate on Immunizations
Summary
The facility failed to ensure that residents were offered and educated on Pneumococcal and Influenza immunizations, as required by their policies. This deficiency was identified during a recertification survey, where it was observed that five residents were not provided with documented evidence of being offered or educated on these immunizations. Specifically, Resident #23 was not offered or educated on the Influenza immunization, and Residents #11, #23, #57, #84, and #93 were not offered or educated on the Pneumococcal immunization. The facility's policies, last reviewed in 2023 and 2024, respectively, require that all residents be educated and offered these vaccines to prevent infections and reduce associated morbidity and mortality. The deficiency was attributed to a lapse in the facility's immunization program due to a personnel transition. The Director of Nursing, who assumed responsibility for monitoring resident immunization statuses after a nurse left the facility, acknowledged falling behind on maintaining the program. This oversight resulted in the sampled residents not being up to date on their immunizations. The report highlights that the facility was unable to provide documented evidence of the residents' immunization statuses or any medical contraindications that would prevent them from receiving the vaccines.
Plan Of Correction
Plan of Correction: Approved April 2, 2025 I. Immediate Correction: 1) Resident #11 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 2) Resident #23 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the Influenza vaccine. Education on benefits and potential risk was provided. Consent was received. Influenza vaccine was administered on (MONTH) 17th, 2025. Family and MD were informed. 3) Resident #57 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 4) Resident #84 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Consent was received. Vaccine scheduled to be administered on (MONTH) 7th, 2025. 5) Resident #93 chart was reviewed by the DNS on (MONTH) 14TH, 2025. Resident was assessed and family was contacted and offered the pneumococcal vaccine. Education on benefits and potential risk was provided. Declination was received secondary to resident’s hospice status. II. Identification of Others: The facility respectfully states that all residents could be potentially affected. The facility will ensure that all residents will be offered the Influenza and Pneumococcal vaccine upon admission and annually and provided with educational material for review. An audit of the entire house was completed by the DNS on the Influenza and Pneumococcal Vaccination to ensure that all new admission and readmissions were offered the Influenza vaccine for the 2024-2025 flu season and Pneumococcal Vaccination with signed consent/declination and education on file. All identified issues were addressed (3/26/25). The facility will ensure that each resident that was offered the Pneumococcal and Influenza immunizations will be followed with documented evidence in EMR to validate compliance. III. Systemic Changes: The Policy and Procedure for Conducting the Influenza Vaccination Program for Residents was reviewed by the DNS and found to be in compliance. The Policy and Procedure for Pneumococcal Vaccination for Residents was reviewed by the DNS and found to be in compliance. On 3/31/2025 all RNs and LPNs received in-service/education on ensuring that all residents are offered the influenza vaccine during the flu season and offered the pneumococcal vaccine upon admission if they meet the criteria and documented in EMR. A matrix tracker was created to monitor the Influenza and Pneumococcal vaccination status of all residents. Newly appointed Infection Control nurse was in serviced/educated on (MONTH) 31st, 2025 regarding her role and responsibility of monitoring, documenting and following up on all residents’ vaccination status. All new and readmissions' immunization status will be requested upon admission and maintained on our Immunization Matrix maintained by our IP Nurse and reviewed daily. All residents will be offered the Flu and Pneumococcal vaccine, if appropriate, and documented in EMR for compliance. IV. Quality Assurance: An audit tool was developed by the DNS to monitor the facility compliance with ensuring that all residents have been offered the Influenza and Pneumococcal vaccine upon admission and annually. The DNS will conduct this audit weekly x3 months. Any identified issues related to the failure to offer vaccination results will be immediately addressed and shared at Morning Meeting. Findings will be reviewed at Quarterly QA Meeting to monitor sustainability. Person Responsible: DNS Date: 4/25/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Offer Recommended Pneumococcal Vaccination: A resident with moderately impaired cognition and diagnoses including kidney disease, dementia, and diabetes had documentation showing prior PCV13 and PPSV23 immunizations, but the medical record did not show shared clinical decision-making or that PCV20/21 had been offered or given. The IP confirmed the resident should have been offered an additional pneumococcal vaccine and did not see that this occurred before survey start; the facility policy stated vaccines would be offered per current CDC guidance.
Influenza vaccine consent and declination documentation was incomplete for two residents. One resident received the flu vaccine without documented education, and another resident declined the vaccine without documented education or a signed declination form. Administrative staff reported there were no current signed consents or declinations, and the facility policy required use of the Patient/Resident Declination/Authorization Form.
Failure to Offer Eligible Pneumococcal Vaccine: A resident with diabetes and Parkinson’s disease had documentation of prior PCV13 and PPSV23 immunizations, making the resident eligible for PCV20 or PCV21 after the required interval. However, the EHR lacked evidence that the resident or representative was offered, educated on, or provided the vaccine, and the DON and ADON confirmed the facility had not offered a PCV vaccine.
Failure to Offer Recommended Pneumococcal Vaccination Updates: The DON, pharmacy, and nursing staff did not ensure two residents were offered pneumococcal vaccine updates based on CDC PneumoRecs guidance. One resident with dementia, CKD, CHF, and COPD had prior PPSV23 and was not offered the recommended PCV update during short-term rehab before moving to LTC status; another resident with hepatic encephalopathy and NASH had prior PPSV23 and PCV13 but was also not offered the recommended PCV20/PCV21 update. Both residents stated they would have accepted vaccines if offered.
A resident with Alzheimer's disease and severe dementia with psychotic disturbance consented to receive the pneumococcal vaccine, but the medical record contained no documentation that it was administered. The DON confirmed the resident did not receive his immunizations.
Failure to Offer Updated Pneumococcal Vaccination: The facility failed to ensure two residents were offered and/or provided updated pneumococcal vaccination per CDC guidance. One resident over age 65 with DM2, kidney failure, and DVT had records showing prior PCV13 and PPSV23 but no evidence of PCV20 or PCV21, and the chart stated the vaccine was not indicated and the resident was up to date. Another resident, younger than 65 with CAD, thyroid disease, and malnutrition, also had PPSV23 documented with no evidence of PCV20 or PCV21, while the consent form likewise stated the vaccine was not indicated and the resident was up to date.
Failure to Offer Recommended Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that recommended pneumococcal vaccinations were offered and/or that shared clinical decision-making regarding pneumococcal vaccinations occurred for 1 of 5 residents reviewed for immunizations, R11. A CDC Pneumococcal Vaccine Timing for Adults chart dated 3/2025 indicated that adults 50 years and older who had received PCV13 at any age and PPSV23 at greater than 65 years may choose to receive PCV20 or PCV21. R11's quarterly MDS indicated R11 was [AGE] years old, had moderately impaired cognition, and was diagnosed with kidney disease, dementia, and diabetes. R11's Resident Vaccinations record dated 10/30/25 showed R11 received PPSV23 on 4/15/20, when R11 was greater than [AGE] years old, and PCV13 on 4/11/19. The record also showed R11 refused pneumovax dose 1 on 1/10/13. Review of R11's medical record did not show that shared clinical decision-making occurred or that PCV20/21 had been offered or administered. During an interview on 7/9/26 at 8:26 a.m., the infection preventionist confirmed she reviewed R11's record and stated that R11 should have been offered an additional pneumococcal vaccination, and that she did not see this had occurred before the survey start. The facility's Vaccine for Residents policy dated 4/22/25 stated vaccinations would be offered according to current CDC guidance.
Influenza Vaccine Consent and Declination Documentation
Penalty
Summary
The facility failed to offer and provide, or obtain an informed declination for, influenza vaccination for two residents. Resident 5's EMR documented that no education was provided when she received the influenza vaccine, although consent was documented as confirmed. Resident 8's EMR documented that no education was provided when he declined the influenza vaccine, and the facility was unable to provide a signed Patient/Resident Declination/Authorization Form for the flu vaccine. During interview, Administrative Staff A provided a handwritten list of residents, a copy of the influenza vaccine sticker showing the lot number, expiration date, and administration site, and reported that there were no current signed consents or declinations for the residents' influenza vaccines. Administrative Staff A also reviewed the EMR and stated that the nurse should have documented yes for education when administering the vaccine or when the resident refused. The facility policy stated that consent or declination for the influenza vaccine would be obtained and documented using the Patient/Resident Declination/Authorization Form, and that information regarding influenza and the influenza vaccine would be discussed with the resident and/or responsible party.
Failure to Offer Eligible Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that 1 of 5 residents reviewed for immunizations, R12, was offered, educated on, and provided the pneumococcal vaccination series as recommended by the CDC. R12’s quarterly MDS showed admission to the facility with diagnoses including diabetes and Parkinson’s disease. The EHR documented that R12 received PCV13 on 9/25/19 and PPSV23 on 10/22/20. The CDC Adult Immunization Schedule dated 10/7/25 indicated that persons of R12’s age who previously received both PCV13 and PPSV23 should receive one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose, making R12 eligible after 10/22/2025. However, the EHR lacked evidence that R12 or the resident representative had been offered, educated on, or provided PCV20 or PCV21. During interview, the DON and ADON confirmed that R12 was eligible for PCV20 or PCV21 and that the facility had not offered a PCV vaccine to R12.
Failure to Offer Recommended Pneumococcal Vaccination Updates
Penalty
Summary
The facility failed to offer recommended pneumococcal immunization updates for 2 of 5 residents reviewed for immunizations. One resident had diagnoses including dementia, chronic kidney disease, congestive heart failure, and chronic obstructive pulmonary disease, and his vaccine history showed receipt of PPSV23 in 2011. PneumoRecs VaxAdvisor recommended one dose of PCV15, PCV20, or PCV21 at least one year after the last PPSV23 dose, but the resident’s physician orders did not include vaccinations and the facility did not offer the update while he was in short-term rehabilitation; the DON stated the resident later moved to LTC status and missed the vaccine clinic held in April, with the next clinic planned for the end of July. The resident’s family member stated she could not recall the facility discussing additional vaccinations, but would have agreed if one had been recommended. The second resident had diagnoses of hepatic encephalopathy and nonalcoholic steatohepatitis, with moderately impaired cognition and substantial assistance or dependence for ADLs. Her vaccine history showed PPSV23 in 2017 and PCV13 in 2020, and PneumoRecs VaxAdvisor recommended one dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. Her physician orders did not include vaccines, and she stated no vaccines had been offered or received since admission, though she would have accepted them if recommended. The DON stated vaccines would be recommended at the end of the resident’s short-term stay, and staff interviews showed immunization review was handled by the DON and pharmacy during vaccine clinics rather than by nursing staff assessing eligibility on admission.
Failure to Provide Ordered Pneumococcal Immunization
Penalty
Summary
The facility failed to ensure that each resident either received the pneumococcal immunization or had documentation of a medical contraindication or refusal. Resident 10, who was admitted with diagnoses including Alzheimer's disease and severe dementia with psychotic disturbance, had an Immunization Consent dated 3/4/26 indicating consent for the pneumococcal vaccine to be administered on 3/10/26. However, review of the medical record from 6/22/26 through 6/29/26 found no documentation that the pneumococcal vaccine was actually given. During an interview on 6/29/26 at 2:54 PM, the DON stated that Resident 10 did not receive his immunizations.
Failure to Offer Updated Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure 2 of 5 residents, R12 and R27, were offered and/or provided updated pneumococcal vaccination in accordance with CDC guidance. Review of the current CDC pneumococcal vaccine recommendations showed that adults age 65 and older who previously received PCV13 and PPSV23 at age 65 or older may receive PCV20 or PCV21, or no additional pneumococcal vaccines based on shared clinical decision making, and adults age 65 and older who received PCV13 at any age and PPSV23 before age 65 should receive a single dose of PCV20 or PCV21 at least 5 years after the last pneumococcal vaccine dose. R12's admission MDS indicated R12 was over age 65 and not up to date on pneumococcal vaccination, and the record stated R12 was not offered the pneumococcal vaccination. R12 had diagnoses including DM2, kidney failure, and DVT. Although R12's Resident Vaccine Administration Consent Form stated vaccines would be given per PCP order and CDC guidelines, it also stated a pneumococcal vaccine was not indicated and R12 was up to date. The MICC report showed R12 received PCV13 on 2/9/16 and PPSV23 on 3/17/15, with no evidence of PCV20 or PCV21 administration. R27's admission MDS indicated R27 was older than 50 and younger than 65 and was up to date on pneumococcal vaccination. R27 had diagnoses including coronary artery disease, thyroid disease, and malnutrition. R27's Resident Vaccine Administration Consent Form stated vaccines would be given per PCP order and CDC guidelines, but also stated a pneumococcal vaccine was not indicated and R27 was up to date. The MICC report showed R27 received PPSV23 on 7/30/18, with no evidence of PCV20 or PCV21 administration. During interview, the DON, who was also the IP, stated all residents were assessed on admission for vaccine status using the MIIC report and a pneumococcal vaccination application and would be offered any recommended vaccines, and stated all residents and/or resident representatives should be offered, educated on, and provided all recommended vaccinations. The facility policy required residents to be assessed within 5 days of admission for immunization status and eligibility for pneumococcal vaccine, and within 30 days to be offered the vaccine when indicated.
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