Failure to Offer Updated Pneumococcal Vaccination per CDC Guidelines
Penalty
Summary
The facility failed to offer the updated pneumococcal vaccination to three residents, as required by its own policy and CDC recommendations. According to the facility's policy, residents are to be assessed for pneumococcal vaccine eligibility upon or prior to admission, and the vaccine is to be offered within thirty days if indicated. Documentation review revealed that three residents had previously received earlier versions of the pneumococcal vaccine (PCV13 and/or PPV23), but there was no evidence that they were offered the most recent pneumococcal vaccine (PCV20 or PCV21) in accordance with current CDC guidelines. The Nurse Manager-Infection Preventionist confirmed the absence of documentation indicating that these residents were offered the updated vaccine. Specifically, one resident had received PCV13 in 2019, another had received PCV13 in 2015 and PPV23 in 2011, and a third had received PCV13 in 2016 and PPV23 in 2007. In each case, CDC recommendations called for consideration of a dose of PCV20 or PCV21 after a specified interval, but there was no record that these recommendations were followed or that the residents were offered the updated vaccine. The facility uses the CDC's PneumoRecs VaxAdvisor tool to determine vaccine recommendations, but this process was not documented for the affected residents.