Failure to Obtain Proper Consent for Pneumococcal Vaccination
Penalty
Summary
The facility failed to implement its policies and procedures regarding pneumococcal immunizations for one resident. An 86-year-old resident with severe cognitive impairment, as indicated by a BIMS score of three out of 15 and diagnoses including dementia, anxiety, mood disturbance, and hypertensive heart disease with heart failure, received the Prevnar 20 pneumococcal vaccine. The resident required partial to moderate assistance with activities of daily living and was not up to date on the pneumococcal vaccine, as the vaccine had previously been offered and declined. The deficiency occurred when the infection preventionist (IP) signed the vaccination consent form on behalf of the resident, rather than obtaining consent from the resident's representative. The resident's representative was not notified or asked for consent prior to the administration of the vaccine and only learned of the vaccination after the resident complained of arm pain. Review of the electronic medical record confirmed the absence of documentation showing that the representative was notified or gave consent for the vaccination.