Failure to Offer Updated Pneumococcal Immunizations per CDC Guidance
Penalty
Summary
Surveyors determined that the facility failed to offer recommended pneumococcal immunizations to five residents who were reviewed for immunizations. The facility's policy required that residents be assessed for eligibility to receive the pneumococcal vaccine upon admission and, when indicated, be offered the vaccine within 30 days. The policy also stated that administration of the vaccine should follow current CDC recommendations. However, clinical record reviews revealed that several residents had received previous pneumococcal vaccines prior to admission, but there was no documentation that the facility offered updated pneumococcal vaccinations in accordance with the latest CDC guidance. Specifically, the records for five residents showed that although they had received earlier versions of the pneumococcal vaccine (such as Prevnar 13 and PPSV23), there was no evidence that the facility assessed or offered updated vaccines as recommended by the CDC's October 2024 guidance. For example, one resident had received Prevnar 13 in 2016 and PPSV23 in 2001, but there was no documentation of an offer for an updated vaccine. Another resident had received Prevnar 13 in 2022, but the record did not show that the facility offered the required follow-up vaccine (PCV20 or PCV21) one year later. The lack of documentation extended to all five residents reviewed, with no evidence that the facility engaged with the residents or their representatives to decide on updated pneumococcal vaccination, as required. This deficiency was identified through clinical record review, policy review, and staff interviews, and it was noted that the facility had previously been cited for a similar issue.
Plan Of Correction
Residents 11, 18, 19, and 29 (or their resident representative) have been contacted by the facility's medical records representative and provided education and handouts, as well as an offer for the updated vaccine. As the resident or representative's decision is conveyed, the outcome was/will be annotated in the medical chart on the Pneumococcal Consent, in the administration record, and under the immunization tab in each resident's chart. Resident #23 has ceased to breathe on July 21, 2025. A facility audit was completed on 7/22/25 to identify all residents who are due for Pneumococcal Immunization. Residents due for the vaccine will be offered a Prevnar 20 per the recommendation of the Medical Director. Resident education will be provided with each resident's consent. Education was provided to clinical staff and the admissions director, ensuring they are familiar with and aware of the Prevnar 20 vaccine and the need to offer the vaccine to incoming residents or their responsible parties. Weekly audits will be conducted for one month and bi-weekly for three months on all new residents to assure compliance with the requirements set forth in the vaccine program. Findings will be presented to the Quality Assurance Performance Improvement committee for recommendations, including an explanation of any identified variance infractions.