Failure to Document and Offer Pneumococcal Immunizations
Penalty
Summary
The facility failed to ensure that residents were offered the pneumococcal immunization as required by policy. For three of five sampled residents reviewed for immunizations, documentation was missing or incomplete in the electronic clinical record. One resident with diabetes had no record of being offered the pneumococcal vaccine. Another resident with a history of stroke was noted as up to date on the vaccine in an assessment, but there was no documentation of when the immunization was given or offered. A third resident with heart failure and moderate cognitive impairment was documented as having declined the vaccine, but there was no record of when education or the offer was provided. The Director of Nursing confirmed that the required documentation was not present for these residents.