Failure to Offer and Document Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to provide education, assess eligibility, offer, and administer pneumococcal vaccinations according to CDC recommendations for four out of five residents reviewed for immunizations. Facility policy required that all residents be offered vaccines unless medically contraindicated, and that education and information be provided prior to vaccination. However, review of medical records and immunization documentation revealed that several residents either were not offered the current recommended pneumococcal vaccines (PCV20 or PCV21), or there was no documentation of such offers, consents, or refusals. One resident with moderate cognitive impairment had consented to receive the pneumococcal vaccine but later refused the older PCV13 vaccine, and there was no evidence that the current vaccine was re-offered. Another resident, who was cognitively intact, had no record of being offered, accepting, or refusing the pneumococcal vaccine. A third resident with severe cognitive impairment had refused the older PPSV23 vaccine, but there was no documentation that the current vaccine was offered to the resident or their representative. A fourth resident with severe cognitive impairment had documentation of a previous pneumococcal vaccine but lacked details on which vaccine was given and when, and there was no record of being offered the current vaccine. Interviews with nursing and administrative staff revealed uncertainty about who was responsible for coordinating vaccine consents and administration, especially after the departure of the Infection Preventionist. Staff were unable to locate additional consents or administration records, and there was a lack of clarity regarding oversight of the immunization process. This resulted in incomplete documentation and failure to ensure residents were appropriately assessed and offered the current pneumococcal vaccines as per CDC guidelines.