Failure to Offer and Document Pneumococcal Vaccine and Education
Penalty
Summary
The facility failed to ensure that a resident was offered the pneumococcal vaccine, nor was there documentation of the resident's refusal or acceptance of the vaccine, or education on the risks and benefits. The facility's policy required that residents be offered the pneumococcal vaccine, with consent obtained and education provided, unless medically contraindicated. However, review of the resident's medical record showed that although the resident was assessed as cognitively intact and able to make their needs known, there was no evidence that the vaccine was offered or that education was provided. The resident had a history of receiving one pneumococcal vaccine, but according to the PneumoRecs VaxAdvisor tool, an additional dose was required to be up-to-date, and this was not addressed by the facility. Interviews with the resident, the DON, and the Regional Clinical Director confirmed that the correct process was not followed. The resident stated they had not been offered or educated about the pneumococcal vaccine and was unaware of the risks and benefits. Both the DON and the Regional Clinical Director acknowledged that the resident needed another dose and that the required process for offering and documenting the pneumococcal vaccine, including education, was not followed.