Failure to Administer Ordered Pneumococcal Vaccine
Penalty
Summary
The facility failed to ensure that a resident was offered and/or provided the recommended pneumococcal vaccine series as outlined by the Centers for Disease Control (CDC). Specifically, the resident's immunization record showed that she had previously received PPSV23 and PCV13 vaccines, and there was a physician order for the administration of PCV20. However, a review of the medication administration record (MAR) revealed no evidence that the PCV20 vaccine was administered to the resident, despite the vaccine being ordered and delivered to the facility. Further document review and staff interview confirmed that the consent for immunization had been obtained and the vaccine was available, but the administration had not occurred. The facility's own policy required that consent be obtained and the pneumococcal vaccination be administered per physician order, with documentation in the resident's medical record. This process was not completed for the resident in question, resulting in a failure to follow established immunization protocols.