Failure to Offer and Document Pneumococcal Vaccines
Penalty
Summary
The facility failed to ensure that pneumococcal vaccines were offered to three out of five sampled residents reviewed for vaccines. According to the facility's policy, all residents should be offered the pneumococcal vaccine upon admission, and documentation should be maintained regarding whether the vaccine was accepted or declined. However, record review showed that there was no documentation indicating that three residents had been offered the pneumococcal vaccine at the time of their admission. Interviews with the Infection Preventionist (IP) confirmed that the process involved sending letters to families of residents unable to make decisions for themselves and directly asking those who could. The IP also stated that immunization status and decisions were to be documented in the clinical record. Despite this, there was no documentation for the three residents in question, and it was confirmed that at least one resident was due for another pneumococcal vaccine, while another had not received the vaccine at all.