Failure to Offer Updated Pneumococcal Vaccinations per CDC Guidelines
Penalty
Summary
The facility failed to offer pneumococcal vaccinations in accordance with CDC recommendations to five residents over the age of 65, as required by facility policy and national standards. Record reviews showed that these residents either received only partial pneumococcal vaccination series or had not been offered the recommended updated vaccines, such as PCV15, PCV20, or PCV21, at the appropriate intervals after previous doses of PPSV23 or PCV13. One resident had previously refused pneumovax vaccinations, but there was no evidence that updated vaccine options were offered as per current guidelines. Interviews with facility staff, including the Regional Director of Clinical Services and the Infection Preventionist, revealed that the facility did not follow up on pneumococcal vaccine updates. The staff relied on providers to order vaccines and did not ensure that residents were offered vaccinations in line with CDC recommendations. The admission process did not adequately assess or act upon the need for updated pneumococcal vaccinations, resulting in missed opportunities for residents to receive appropriate immunizations.