Failure to Provide Updated Pneumococcal Immunization
Penalty
Summary
The facility failed to provide the recommended pneumococcal immunization to a resident, identified as Resident 4, as required by their policies and procedures. Resident 4 was admitted to the facility in February 2022 and had previously received two pneumococcal vaccines, Pneumovax 23 and Prevnar 13, prior to admission. According to CDC guidance, Resident 4's pneumococcal vaccinations would not be complete until she received a Prevnar 20 or Prevnar 21 at least five years after her last dose. However, there was no documented evidence that the facility offered Resident 4 the updated pneumococcal vaccination when she became eligible. An interview with the infection control preventionist, Employee 1, confirmed that the facility missed obtaining consent and offering the updated pneumococcal vaccination to Resident 4 when she became eligible. Employee 1 acknowledged that at the time of sending Prevnar 20 consents in January 2024, Resident 4 was not yet eligible. When she became eligible, the facility failed to follow up and offer the vaccination. This oversight was confirmed during a staff interview, and Resident 4's family later indicated their desire for her to receive the vaccination.
Plan Of Correction
Responsible party for resident number 4 was contacted and offered pneumonia vaccine. He initially consented, but due to resident's decline in condition, he has revoked his consent. A baseline audit of current residents was conducted. Consents for those that are eligible this year will be sent to responsible parties/residents. Residents that consented for pneumonia vaccines will be scheduled based on eligibility date. An audit of eligible residents will be conducted to ensure administration of pneumonia vaccine as ordered monthly for 3 months. Results of this audit will be reviewed by the Quality Assurance Committee to evaluate the need for ongoing auditing or further education.