Failure to Offer and Document Timely Pneumococcal Vaccination
Penalty
Summary
The facility failed to ensure that a resident was offered a timely pneumococcal vaccination to complete the recommended vaccine schedule. The resident, who had a history of type two diabetes mellitus with circulatory complications and chronic diastolic (congestive) heart failure, had previously received the PPSV23 vaccine on three occasions. However, there was no documentation in the clinical record or immunization audit report indicating that the resident had received any of the other recommended pneumococcal vaccines, such as PCV13, PCV15, or PCV20. The resident's record listed these vaccines as pending, and a multi-vaccine consent form indicated eligibility but lacked a signature for consent or declination. Interviews with the Infection Preventionist (IP) revealed that the facility determined vaccine eligibility based on consent, vaccination history, and CDC recommendations. The IP confirmed that the resident had not received the PCV vaccines and that pending immunization status indicated the resident was due and had given consent. The facility's policy required vaccination upon admission and as per CDC guidelines, with documentation of administration, refusal, or non-vaccination in the electronic health record. Despite these procedures, the required pneumococcal vaccine was not administered, and proper documentation of consent or refusal was not present.