Failure to Administer Pneumococcal Vaccine Despite Signed Consent
Penalty
Summary
A deficiency occurred when the facility failed to provide the pneumococcal immunization to a resident who had signed consent for the vaccine. The facility's policy required assessment of vaccination status within five working days of admission and administration of the vaccine within thirty days unless medically contraindicated, already given, or refused. In this case, the resident had a re-entry admission and a documented moderate cognitive impairment, with a BIMS score of 12. The electronic medical record indicated that the resident refused the pneumococcal vaccine, but there was also an uploaded, signed informed consent for the vaccine dated the same day as admission. During interviews, the Infection Preventionist was unable to explain the discrepancy between the documented refusal and the signed consent. The Infection Preventionist later confirmed that the resident still wanted the vaccine but was unable to verify if the vaccine had been administered, citing lack of access to the Florida Shot Finders website. No follow-up was provided to the surveyor regarding the resident's vaccination status, resulting in a failure to ensure the resident received the pneumococcal immunization as per facility policy.