Failure to Offer and Document Pneumococcal Vaccination Consent
Penalty
Summary
The facility failed to ensure that a resident was offered and/or received the recommended pneumococcal immunization according to current CDC guidelines. The Assistant Director of Nursing/Infection Prevention Nurse stated that vaccines are offered to residents upon admission and annually, including all types of pneumococcal vaccines. Review of the resident's records showed she had previously received PCV-13 and PPV23 vaccines, making her eligible for a dose of PCV20 based on shared clinical decision-making recommendations. However, there was no documentation of consent or refusal for the PCV20 vaccine for this resident. The facility's policy requires that pneumonia vaccines be offered upon admission and annually, with residents or their representatives asked to indicate their wishes regarding the vaccine, but this process was not documented for the resident in question.