Failure to Document and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to follow its own policies and procedures for immunizing residents against pneumococcal disease in accordance with national standards of practice. Specifically, nine residents were not vaccinated with the pneumococcal vaccine, and there was no documentation in their electronic medical records regarding the offering of the vaccine, education about its benefits and side effects, or any record of refusal. Review of physician orders and immunization records for these residents showed no evidence of pneumococcal vaccination or related documentation from admission through the review period. During interviews, the Infection Preventionist (IP) acknowledged that while pneumococcal vaccines are supposed to be offered upon admission and during influenza season, there was no proof of offering the vaccine to the affected residents except for undated and incomplete consent forms. The IP also stated that refusals were not routinely documented in the residents' charts and that vaccination forms were not properly completed. Facility policies require assessment for vaccine eligibility, offering the vaccine within thirty days of admission, and documentation of refusals, but these procedures were not followed for the residents in question.