Failure to Accurately Track and Administer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure accurate tracking and administration of pneumococcal vaccinations for three of five residents reviewed. For one resident with a history of right femur fracture, COPD, and chronic respiratory failure, there was no record of any pneumococcal vaccination, and the Michigan Care Improvement Registry (MCIR) indicated the resident was overdue for the vaccine. Another resident with heart failure, dementia, and anxiety disorder had received a pneumococcal vaccine in the past, but was overdue for an additional dose according to MCIR and CDC guidelines, with no record of the vaccine being administered by the facility. A third resident with diabetes, acute respiratory failure, and liver transplant status had received previous pneumococcal vaccines, but was also overdue for the recommended dose, with discrepancies noted between the facility's records and the MCIR. During an interview, the LPN responsible for infection control stated that she relied on consent forms included in admission paperwork before offering vaccinations and did not approach residents directly to obtain consent. The LPN also demonstrated a lack of current knowledge regarding CDC guidelines for pneumococcal vaccination, relying instead on outdated practices and assumptions about vaccine requirements based on age and timing of previous doses. These actions and inactions resulted in residents not receiving timely and appropriate pneumococcal vaccinations as required by facility policy and CDC recommendations.