Failure to Offer Prevnar 20 Vaccine per Updated Guidelines
Penalty
Summary
The facility failed to offer the Prevnar 20 (PCV20) pneumococcal conjugate vaccine to residents in accordance with the most recent recommendations from the CDC and ACIP. Record reviews for four residents revealed that while the facility either administered or offered the PPSV23 vaccine, there was no documentation that the PCV20 vaccine was offered or administered, nor was there evidence that residents had received PCV20 prior to admission. In cases where residents declined the PPSV23 vaccine, the declination forms did not indicate that PCV20 was also offered as an option. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, confirmed that the facility's practice was to offer only the PPSV23 vaccine to residents and that staff were unaware of the requirement to offer PCV20 in accordance with updated ACIP guidelines. The facility's immunization policy, last revised in 2019, did not specify the brand of pneumococcal vaccine to be offered, and staff reported that Prevnar 20 had never been offered to residents.