Failure to Administer Pneumococcal Vaccine per Policy
Penalty
Summary
The facility failed to implement its policies and procedures regarding pneumococcal vaccinations for one of five sampled residents. Specifically, a resident over the age of 65 with multiple medical conditions, including a history of intracranial injury, atrial fibrillation, heart failure, legal blindness, and benign prostatic hyperplasia, did not receive the pneumococcal vaccine as required. The resident had documented cognitive impairments and required assistance with daily activities. According to the minimum data set assessment, the resident's pneumococcal vaccination was not up to date, and there was no documentation that the resident declined the vaccine. A consent form for the pneumococcal vaccination was signed by the resident's representative, indicating authorization for the vaccine to be administered. However, a review of the electronic medical record revealed no documentation that the vaccine was given, nor was there evidence of a documented refusal by the resident. Staff interviews confirmed that the vaccine had not been administered and that the process for ordering and administering the vaccine was not completed as required.