Failure to Screen, Offer, and Document Pneumococcal Vaccination
Penalty
Summary
The facility failed to conduct proper eligibility screening, offer, and provide education regarding the pneumococcal (pneumonia) immunization for a resident. Clinical record review showed that the resident, who had moderately impaired cognition and diagnoses including Alzheimer's disease, anxiety, and hypertension, had received the pneumococcal polysaccharide vaccine (PPV23) in the past. However, there was no documentation that the resident was offered or educated about the recommended follow-up pneumococcal vaccines (PCV20 or PCV21), nor was there documentation of consent or refusal for these vaccines. Staff interviews revealed that pneumonia vaccinations were only offered at admission, and subsequent eligibility for additional vaccinations was not routinely assessed or offered. The facility's policy required that all residents be given the opportunity and encouragement to receive pneumococcal vaccinations, but the process for ongoing review and offering of vaccines was not followed. The physician was expected to review vaccination history and order immunizations, but this did not consistently occur, resulting in a lack of compliance with CDC recommendations and facility policy.