Deficient Pneumococcal Vaccine Education, Consent, and Administration
Penalty
Summary
The facility failed to properly educate residents or their representatives on the currently available and CDC-recommended pneumococcal vaccines for two individuals. In both cases, the immunization consent forms signed by the residents' representatives did not specify which Vaccine Information Statement (VIS) was provided, nor did they include information about the PCV15, PCV20, or PCV21 vaccines. Instead, the forms referenced outdated recommendations and vaccines, such as PCV13 and PPSV23, which are no longer recommended for routine use among adults aged 65 and older. There was also no documentation in the electronic medical records by the physician or Infection Preventionist regarding any discussions or education provided about the benefits or risks of pneumococcal vaccination. Additionally, the facility did not administer a pneumococcal vaccination or document any clinical reasons for withholding it for one resident, despite the legal guardian having provided consent for the vaccination more than two months prior. The resident's medical record lacked any documentation of contraindications or clinical considerations for not administering the vaccine. The Infection Preventionist confirmed that the vaccination had not been given and that the process was still ongoing, with no further explanation or documentation provided. The facility's vaccine consent forms and immunization policies were also found to be outdated, referencing vaccines and recommendations that are no longer current according to the CDC. The standing orders and immunization policy documents did not reflect the most recent guidance, which recommends the use of PCV15, PCV20, or PCV21 for adults at risk. The most current VIS, which includes updated recommendations, was not provided to the residents or their representatives, resulting in a lack of informed decision-making regarding pneumococcal vaccinations.